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 . 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 . 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, 45,46,47]. 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 . Grant and Boersma  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.  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 . This can be supported by Goffman’s argument that people are likely to present themselves in a light that seems favourable .
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 . This issue of self-representation was very clear in our study and is in line with the study by Guassora, Reventlow & Malterud  where patients presented themselves as responsible in dialogues about lifestyle and tried to defend themselves against shame .
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.  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. . This paradox of control places many people in an untenable situation whereby they feel guilty about failing to perform the ideal behaviours  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 . However, stigmatization of persons with overweight or obesity threatens psychological and physical health [14,15,16, 41] and generate health disparities . Findings in a study by Täuber et al.  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 , Tangney & Fisher  and Tracy, Robins & Tangney . 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  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  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. , 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.  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 . In a study by Guassora et al. , 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 . 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 . 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.  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.
Trustworthiness, strengths and limitations
A qualitative design may provide insight into complex phenomena. In line with the hermeneutic approach employed in this study, there is always a possibility of ambiguity and different interpretations of the meaning of the text. Addressing aspects of credibility, dependability, transferability and confirmability to increase trustworthiness is important . We argue that the credibility, confirmability and dependability of the findings were strengthened by coherently and systematically analysing data using inductive coding [34, 35] and categorization in the interpretation process (hermeneutical circle) [28, 38]. The discussion of the findings on several occasions, as well as the variation in the disciplinary backgrounds of the author and co-authors, who are public health nurses (ES and BSH), a nurse specializing in health education (GF) and a psychiatric nurse (ALH), enriched the analysis and increased trustworthiness and confirmability. The analysis and data interpretation were influenced by the authors’ preunderstanding, therefore the findings are a constructionist coproduction of the participants’ perception of reality [30, 33, 61]. The first author (ES) conducted the data collection and the co-authors read all the transcribed interviews in order to minimize potential bias. The first author (ES) has several years of clinical experience as a public health nurse and also worked in an interdisciplinary team helping children, adolescents and their families to change their dietary and activity habits. Her background provided a preunderstanding and experienced based knowledge of the research phenomenon, in addition to valuable insights concerning lifestyle change and social stigma. The second author (BSH) and third author (GF) also have experience of health promotion and health education, which provides a valuable and useful overview of health promotion perspectives. The fourth author (ALH) contributed understanding of and valuable insights into the psychological and emotional findings. Another strength of this study is the semi-structured in-depth interviews, which allowed the participants to focus on their needs and perceptions. Each interview lasted from 66 to 131 min, providing opportunities to elaborate on the questions and follow up the responses. The variety in age, gender and socioeconomic status strengthens the utility and transferability of the findings, which are enhanced by the rich descriptions of the context, the informants from five different HLCs in Western Norway, the data collection and analysis, as well as the inclusion of quotations from a number of participants. Information power  guided the data collection in order to ensure a variety of perceptions. This paper meets the requirements of the COREQ  checklist.
The strength of our study is the contribution to knowledge of HLC participants’ experiences of living with overweight or obesity and seeking help to change their dietary and activity habits. As a relatively new health service, there is a need for a better understanding of this phenomenon in order to provide a high quality health service. The findings of the Finnish study, in which nurses and GPs reported that the participants’ unwillingness to change lifestyle behaviour was a major barrier to lifestyle change , are in contrast to our findings, where the participants themselves stated that it is not unwillingness but rather shame, guilt and ambivalence towards assuming responsibility that hinder them. The unwillingness reported by the nurses and GPs may be a result of stigmatization and prejudice. However, the fact that it differs from the perceptions of the participants in the present study is also an interesting issue, which highlights the importance of the service user perspective.
Some methodological limitations should be taken into account when interpreting the results. Providers recruited participants from ongoing lifestyle interventions, thus it is possible that the participants were selected because it was known that they were satisfied with the HLC programme. The participants may have also been influenced by the ongoing process of change, and participation in both dietary and activity interventions over a period of time prior to the interviews.