Healthy Life Centre participants’ perceptions of living with overweight or obesity and seeking help for a perceived “wrong” lifestyle - a qualitative interview study

Overweight and obesity present an increased risk to health and are major risk factors for a number of non-communicable diseases (NCDs) including type-2 diabetes (T2DM), cardiovascular disease (CVD), chronic obstructive pulmonary disease (COPD), some types of cancer, musculoskeletal disorders and mental health problems [1–3]. The risk of NCDs is primarily driven by tobacco use, physical inactivity, unhealthy diet and alcohol abuse [2]. The Norwegian Directorate of Health recommends the establishment of Healthy Life Centres (HLCs) in all municipalities in order to assist persons at risk of NCDs, or in need for support for health behaviour change or weight management [4]. Empirical evidence highlights the importance of lifestyle change as a key component of risk reduction and the promotion of healthy development [5]. A healthy lifestyle is associated with protective risk factor levels and lower levels of symptoms and illness, including psychological illness [6]. The outcome of educational interventions aimed at increasing the level of physical activity (PA) with follow up in primary care is uncertain [7]. In addition, a quantitative study of HCL lifestyle interventions reveals that participation in a prescribed group-based exercise programme for 3 months may improve physical fitness and Health Related Quality of Life (HRQoL) [8]. In a literature review, the main barriers to the success of educational programmes were found to be psychological and environmental, but also socio-economic [9].

The individualization of health has been discussed in recent decades and this ideological shift in health promotion makes every individual responsible for her/his own health and for learning to adopt rational lifestyle behaviours [10, 11]. Studies of attitudes towards obesity show that as many as 72% mentioned individual reasons for obesity. Media and public health campaigns may solidify beliefs that obesity is due to individual causes, thus increasing the stigma [12]. A Norwegian study of normative newspaper messages on obesity and health, revealed a focus on bodily conformity, linking leanness with attractiveness, obesity with ugliness and lack of control with lack of responsibility [13]. Numerous studies have documented harmful weight-based stereotypes such as persons with overweight and obesity are lazy, unintelligent, have poor willpower and are noncompliant with weight-loss treatment [14, 15]. These stereotypes give rise to stigma, prejudice and discrimination against obese persons in multiple domains of life [15, 16], thus contributing to their lower psychological functioning and well-being [17]. Stigma can be a barrier to seeking help for weight management [18, 19].

In a qualitative study of primary care physicians and nurses responsible for lifestyle change, a majority reported that a major barrier was patients’ unwillingness to change their habits [20]. In earlier studies of participants’ perceptions of self-responsibility in an intervention to prevent T2DM, the informants had an ambivalent attitude towards self-responsibility and their own role in lifestyle change and its maintenance [21]. A majority of lifestyle intervention participants characterize lifestyle change as a constant struggle [21, 22] and weight management as an endless battle against temptations [21]. In a study about lifestyle issues in clinical dialogues, patients took a proactive role in defending themselves against shame and made great efforts to present themselves as responsible agents in matters of health [23]. The participants in a previous qualitative study of Norwegian HLCs described how earlier life experiences and emotional baggage can influence lifestyle change and questioned whether or not HLCs can actually help participants with substantial emotional baggage to change their lifestyle [22]. In addition, HLC stakeholders have a wide range of expectations and they describe HLCs as a concept in development [24]. In a newly published cross-sectional study of the characteristics of participants who started attending a HLC, the most frequent reasons were being overweight, wanting to increase physical activity, improve dietary habits and cope with musculoskeletal health challenges [25].

The scientific evidence of the long term effects of health promotion interventions in primary care is still not convincing [9, 26, 27]. There are few studies of lifestyle interventions in HLCs in Norway and sparse knowledge of the participants’ background, and help-seeking needs. There is a need for a better understanding of the participants’ experiences and perceptions in order to understand how HLCs can provide a qualitatively good health service and support them to change their lifestyle. More research is needed to understand their perspective, as well as the more complex, less articulated influences such as knowledge, skills, motivation and emotional status that can lead to weight gain and inactivity, but also to change. The aim of this study was therefore to explore HLC participants’ experiences of living with obesity and perceptions of seeking help to change dietary and activity habits.

The analysis resulted in one main theme: Searching for dignity, which was based on two themes: Needing to justify avoidance of personal responsibility and A desire to change.

This study explored how HLC participants experienced living with overweight or obesity and their perceptions of seeking help to change their dietary and activity habits. Below, we discuss the findings in the context of existing literature within this field.

The results suggest that the participants are basically seeking dignity to gain a better self-image and maintain their integrity. Several of the participants described low self-esteem and mental health issues, while some were painfully aware that they weigh too much and their weight issues reflect a deep sense of unworthiness. The desire to change may be seen as a wish to be normal and thereby feel worthy. Dignity can be related to self-esteem, as it refers to the worth of human beings, the right to be valued and respected. According to Schopenhauer, dignity is the opinion of others about our worth, while a subjective definition of dignity is our fear of others’ opinion [39]. This can illuminate the basic search for dignity in all human beings and in particular for persons with overweight and obesity.

There are a number of possible explanations for this search for dignity. It can be seen as a response to the stigma linked to being afflicted by overweigh or obesity. Goffman describes stigma as a deviation from our expectations of normality [40]. When reporting how they experienced living with overweight or obesity, the participants in our study described negative feelings related to body image, self-esteem and confidence (feelings of shame), feeling bad about not adhering to the dietary and activity plan (guilt) and lack of self-management in daily life (discouragement). This is consistent with previous studies showing that persons afflicted by overweight or obesity perceive that they are less worthy and experience a great deal of guilt, discouragement and shame [14, 23, 41, 42]. Several previous studies have described lifestyle change as an eternal struggle [22, 43], leading to feelings of unworthiness [14, 42, 44].

The participants in our study tried to explain the reasons behind their weight challenges and why they find change so difficult. In some cases it was a reaction to grief, the loss of a spouse, while others perceived challenges to their identity related to losing a job or being diagnosed with a chronic disease. These findings are in line with earlier studies and support the view that changing lifestyle habits is difficult as psychological and emotional distress can influence the ability to change [22, 45–47]. Participants with complex challenges and insufficient coping strategies, many of whom suffered from mental health problems, often struggled with follow up [8, 24]. Our participants also reported previous experiences of attending slimming programmes and losing weight, but subsequently gaining weight again after the intervention period. Some of them experienced these efforts as a hopeless enterprise and the relapses as shameful. This struggle is supported in earlier studies that the risk of weight regain includes a history of weight cycling and relapses [48]. Grant and Boersma [44] suggest that it is better to understand the nature of the problem rather than change the person. As the dominant counselling approach in weight management programmes is based on behavioural or cognitive behavioural paradigms, the benefits of a psychodynamic approach would be worth further exploration.

Several of the participants in our study reported lack of discipline and willpower as a challenge, and blamed themselves for not having more control. Jallinoja et al. [43] suggest that no matter how self-disciplined individuals are, if the dilemma between pleasure and health are not disentangled, lifestyle change will only be short term. In general, the participants in our study stated that their personal responsibility for a healthy lifestyle and changing their own situation was important to them. These findings are supported by an earlier study, which revealed that participants in an intervention to prevent type 2 diabetes had an ambivalent stance towards self-responsibility, yet constructed themselves as responsible and knowledgeable pro-health persons [21]. This can be supported by Goffman’s argument that people are likely to present themselves in a light that seems favourable [49].

Self-conscious emotions like shame, guilt, embarrassment and pride play a central role in motivating and regulating almost all of people’s thoughts, feelings and behaviour, and differ from basic emotions because they require self-awareness and self-representation [50]. This issue of self-representation was very clear in our study and is in line with the study by Guassora, Reventlow & Malterud [23] where patients presented themselves as responsible in dialogues about lifestyle and tried to defend themselves against shame [23].

The participants in our study expressed and believed that their overweight or obesity was self-inflicted and considered themselves guilty of not eating healthy food and adhering to their dietary and activity plan. This is in line with previous studies where positive attributes are accorded to people who are healthy, while those who become ill or have a less perfect body are blamed and considered self-indulgent, lazy, unmotivated, lacking self-discipline, less competent or even irresponsible and immoral [13, 14, 41, 42]. The personal attributes assigned to persons with overweight or obesity highlight the victim-blaming that occurs [12, 42]. Brownell et al. [51] hold that the two most important words in the national discourse about obesity are personal responsibility and that the concept of personal responsibility for health is deeply ingrained in our culture and political system. They state that good health has become more than a means to achieving personal goals such as greater attractiveness and increased longevity, but symbolizes self-control, hard work, ambition and success in life. Inherent in this symbolism is the concept that the individual controls behaviour, which in turn controls health. [51]. This paradox of control places many people in an untenable situation whereby they feel guilty about failing to perform the ideal behaviours [42] and are ashamed when they become ill, as is the case with the participants in our study (T2DM, CVD, COPD). According to the review by Puhl & Heuer, obese persons are blamed for their weight and a common perception is that weight stigmatization is justifiable and may motivate individuals to adopt healthier behaviours [14]. However, stigmatization of persons with overweight or obesity threatens psychological and physical health [14–16, 41] and generate health disparities [16]. Findings in a study by Täuber et al. [17] suggest that weight bias internalization in the form of moral condemnation contributes to the lower psychological functioning and well-being of people with overweight and obesity. The participants’ perceptions of responsibility in our study are clear, but we suggest that this emphasis on personal responsibility may lead to even greater shame when people experience lack of management or condemnation from society.

The theory of these self-conscious emotions is described by Tangney [50], Tangney & Fisher [50] and Tracy, Robins & Tangney [52]. In relation to shame and guilt, they argue that shame involves negative feelings about the stable, global self («I am a fat person»), whereas guilt involves negative feelings about a specific behaviour or action taken by the self (“I didn’t try hard enough to lose weight”). When the attentional focus is directed towards the public self, such as being publicly exposed as incompetent, it becomes an embarrassment. The public self is always present because it reflects the way we see ourselves through the real or imagined eyes of others [52, 53]. Goffman [40] noted that every social act is influenced by even the slightest chance of public shame or loss of face and people worry about losing social status in the eyes of others.

Some of the participants described isolating themselves from the outside world. This isolation was partly due to depression, but also because of negative feelings attached to self-esteem and body image. According to previous literature, the immediate response to shame is often to retreat or make oneself as small as possible [54, 55], which may explain why some of the participants in our study isolated themselves. There is a tremendous pressure in post-modern Western society to be thin and have a specific body shape, which for many symbolizes self-control, discipline, hard work, success and ability to manage indulgence [42, 54]. In the self-esteem theory, Maslow [56] described self-esteem as a basic human need or motivation that reflects a person’s overall subjective emotional evaluation of her/his own worth. He claimed that all people have a need or desire for a stable and high evaluation of themselves and self-respect in the form of self-confidence, skills and capability. Ignoring these needs produces feelings of inferiority and helplessness, which in turn give rise to basic discouragement.

In general, the participants described their desire for change as feedback from their body. Some seemed to be motivated to change their diet and level of activity by their appearance or health challenges, while for others the desire for change was for preventive reasons. Several participants reported that the seriousness of the health challenges serve as an ultimatum if they want to live longer and achieve better health. Several of our participants were either at risk of or had already developed NCDs as reported in Table 2. This finding is consistent with a previous study by Følling et al. [22], which reported that 91% of the participants in a HLC lifestyle intervention had multi-comorbidities, such as overweight, obesity, T2DB, muscle- and skeletal diseases and psychological issues. It is also in line with previous findings from Samdal et al. [25] describing the reasons for attending a HLC as the wish to increase physical activity and achieve a healthier diet in order to manage overweight, obesity and multiple health challenges. Our study adds to the literature about the challenges involved in health promotion interventions for overweight and obesity. In addition, we add to the literature on help-seeking needs, the underlying importance of self-representation, integrity, acceptance and dignity.

The participants in our study described pride in self-management. They were eager to talk about their initiative to change and the fact that they themselves asked for help. Theories of pride explain that when it comes to motivating social behaviour, pride may be the most important human emotion [52, 57]. Our most meaningful achievements, both on an everyday and life changing level, are accompanied by a feeling of pride. It is likely that pride evolved to provide information about an individual’s current level of social status and acceptance. Self-esteem may be an important part of this process and the development of pride may be closely linked to the development of self-esteem [52]. In a study by Guassora et al. [23], patients described their achievements as matters of honour, shifting from problematic issues to achievements of which they were proud. Our study supports these findings and highlights the meaning of pride in people’s presentations of self. In addition, our study contributes to descriptions of how participants alternate between shame, guilt and pride and how these self-conscious emotions influence the ability to assume or avoid responsibility.

The turning point can appear when the individuals in question understand the severity of the situation and realise that after several attempts and mistakes doing things by themselves, they need help and support from others, as the participants in our study recognized. Asking for help may involve swallowing hubristic pride as described by Tracy & Robins [52]. Studies have shown that individual motivation to lose weight and perceived self-efficacy are associated with better weight loss and beneficial effects on physical health and life satisfaction [58, 59]. Bandura’s theory of self-efficacy, the belief in one’s own ability to manage different tasks and reach specific goals, is important for behavioural change [60]. Previous studies have shown that participants who contacted a HLC themselves more often expressed a will for lifestyle change and less often dropped out than those referred by GPs [8, 24, 25]. Although the participants in the study by Samdal et al. [25] had autonomous motivation, they suggest that interventions have to address impaired self-efficacy. Our findings suggest that the participants experienced hope and self-efficacy related to using their own resources, but most of all as a result of the support they experienced at the HLC, which in turn strengthened their motivation to continue implementing lifestyle changes.

This study explored HLC participants’ experiences of living with overweight or obesity and perceptions of seeking help to change dietary and activity habits. Being stigmatized and feeling shame and guilt for not managing to live a healthy lifestyle and have a normal body, have consequences for people’s psychological and emotional health and affect their quality of life. This study contributes to the descriptions of emotional distress experienced by persons afflicted by overweight or obesity. In addition, the findings add to previous knowledge by illustrating the impact of shame, guilt and pride, as well as demonstrating the complexities involved in assuming responsibility for changing dietary and activity habits. Self-conscious emotions such as shame, guilt and pride play a central role in motivating and regulating almost all of people’s thoughts, feelings and behaviour. It is therefore necessary to address these emotions in lifestyle interventions and offer treatment that takes account of such feelings. It is easy to forget the person living with overweight or obesity when both the person her/himself and the provider are mainly focused on weight loss treatment. Future HLC and health promotion interventions need to educate service users about emotions such as shame, guilt and pride, and their role in food consumption and inactivity so that people with overweight or obesity are able to regulate their intake of food and physical activity. We suggest that regaining positive self-esteem and dignity will lead to the ability to assume personal responsibility for achieving a better quality of life. Weight stigma at individual and system level and as well as responsibility related to dilemmas about the “right” or “wrong” lifestyle should be addressed.