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Living a successful weight loss after severe obesity

Living a successful weight loss after severe obesity INTERNATIONAL JOURNAL OF QUALITATIVE STUDIES ON HEALTH AND WELL-BEING 2018, VOL. 13, 1487762 https://doi.org/10.1080/17482631.2018.1487762 a,b c a,b a,d Eli Natvik , Målfrid Råheim , John Roger Andersen and Christian Moltu a b Department of Health and Caring Sciences, Western Norway University of Applied Sciences, Førde, Norway; Center for Health Research, District General Hospital of Førde, Førde, Norway; Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway; Division of Psychiatry, District General Hospital of Førde, Førde, Norway ABSTRACT ARTICLE HISTORY Accepted 8 June 2018 Purpose: Losing weight and keeping it off for the long term is difficult. Weight regain is common. Experiences of successful non-surgical weight loss after severe obesity are largely KEYWORDS unexplored. We know little about long-term weight loss processes, and how health care Embodiment/bodily services can be of help to those living them. Methods: Drawing on in-depth interviews of 8 experiences; lifestyle change; women and 2 men, the aim of this phenomenological study is to describe the experiences of lived experience; obesity; adults who have been severely obese, who have lost weight and maintained weight loss for phenomenology; well-being the long term (>5 years). Results: Findings show that after severe obesity, sustained weight loss has no endpoint, yet is always easy to end. Keeping weight off means committing to oneself, continuing profound changes and cultivating sensitivity towards oneself and others. A phenomenological understanding of sustained weight loss can inform professionals who deal with health issues and challenges occurring in the life of people leaving severe obesity. From being an unusual condition in the 1970s, the and change, and the risk of enacting stigma and prevalence of severe obesity is increasing in several affecting health negatively. developing countries. If current trends continue, we People’s lived experiences can yield rich examples are facing an epidemic of severe obesity (NCD risk factor to help understand long-term weight loss in concrete collaboration, 2016). Severe obesity is important to ways, and providing an in-depth contextual under- attend to, regarding population health and in clinical standing may guide professional action and encounters. Obesity-related issues may threaten vital life strengthen ethical engagement in clinical encounters functions and limit lifespan. Health risk rises with (Natvik & Moltu, 2016). The aim of the current study increasing body weight, and obesity is related to coron- was to describe lived experiences of adults who have ary heart disease, hypertension, type 2 diabetes, muscu- been severely obese, have lost weight and sustained loskeletal disorders, some cancers, depression and it over a period of at least 5 years. anxiety (National Institute for Health and Care Lifestyle change (diet and exercise modification), Excellence, 2006; National Institutes of Health, 2012; cognitive behavioural therapy, weight loss medica- Prospective Studies Collaboration, 2009;WorldHealth tions and bariatric surgery are treatment strategies Organization, 2017a). Experiences, meanings and atti- for severe obesity (Bray, Frühbeck, Ryan, & Wilding, tudes attached to obesity differ profoundly according to 2016). Weight loss surgery is the most effective inter- severity (Lewis et al., 2010). vention for long-term weight loss, but carries risk of Social stigma, discrimination and withdrawal from mortality, complications and late effects, and health social life and loved ones are consequences for many outcomes are largely unknown (Adams et al., 2012; (Brewis, 2014; Puhl, 2011; Puhl & Heuer, 2009). Weight Colquitt, Pickett, Loveman, & Frampton, 2014; stigma is part of clinical encounters, and health care Puzziferri et al., 2014). Surgery is not an option for providers are not necessarily reflective about this all patients, because of individual preferences—for (Malterud & Ulriksen, 2011; Puhl & Heuer, 2009; example, avoiding risks or advocating fat acceptance Setchell, Gard, Jones, & Watson, 2017). Weight stigma —or societal barriers, such as financial or health sys- in clinical encounters is a paradox, because stigma tem barriers (NCD risk factor collaboration, 2016). affects patients’ health and quality of life negatively, Modest weight loss, 5–10% of initial body weight, is and undermines trust between patients and health sufficient to gain significant health benefits and prevent care providers (Gudzune, Bennett, Cooper, & Bleich, obesity-related illness (Goodpaster et al., 2010;Look 2014; Setchell et al., 2017). This means that health AHEAD Research Group, 2010; Thomas, Bond, Phelan, care providers and patients encounter a tension Hill, & Wing, 2014; Wing & Hill, 2001). Whether modest between supporting initiatives towards weight loss weight loss is experienced as enough may depend on CONTACT Eli Natvik [email protected] Department of Health and Caring Sciences, Western Norway University of Applied Sciences, Førde, Norway © 2018 The Author(s). Published by Informa UK Limited, trading as Taylor & Francis Group. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 2 E. NATVIK ET AL. initial size, weight and health. Non-surgical weight loss Hall, 2016; Marzocchi, Cappellari, Dalle Grave, & initiatives for people suffering from severe obesity typi- Marchesini, 2011;Sharma, 2017). This means that as an cally aim for a loss of 20% or more to achieve health experiential phenomenon, long-term weight loss after benefits (Yumuk et al., 2015). Approximately 20% of severe obesity is largely unexplored. those who obtain weight loss maintain it for one year To gain new insight into sustained non-surgical or longer (Dombrowski, Knittle, Avenell, Araújo-Soares, weight loss after severe obesity, the people who & Sniehotta, 2014; Wing & Phelan, 2005). Many termi- have accomplished this (or not) and their experiential nate weight loss efforts in an early phase, and weight life is an important starting point. Research based in regain is frequent (Christiansen, Bruun, Madsen, & the first-person perspective can deepen current Richelsen, 2007;Knowler et al., 2009;Look AHEAD understandings of and meanings attached to long- Research Group, 2014;Ryanet al., 2010; Thomas et al., term weight loss. Our research question was “What 2014). This means that long-term maintenance of is it like for people with severe obesity to lose weight weight loss via lifestyle changes is possible, but difficult and keep it off for the long-term?” (Frühbeck, Toplak, Woodward, Halford, & Yumuk, 2014; MacLean et al., 2015). Methodology The National Weight Control Registry (NWCR) has identified successful weight loss maintainers and To explore experiences of weight loss, we designed a described their strategies, health behaviours and qualitative study grounded in a phenomenological body weight trajectories since 1993. Participants approach as described by van Manen (2014). Our ambi- with larger initial weight loss have been most success- tion was to understand the ways in which weight loss ful in the long term (Thomas et al., 2014; Wing & following severe obesity incorporates the person’sliv- Phelan, 2005). Successful participants regained more ing. Weight loss is a human phenomenon carrying rapidly, but regained very little after five years, and lifeworld meanings. Lifeworld points to the world of heavier participants followed the same pattern experience, our particular world that we intimately (Thomas et al., 2014). Maintaining weight loss for 2 know and take for granted (Husserl, 1954/1970). years or longer was associated with maintaining larger Ambiguity permeates our lifeworld as it is both all we weight loss at 5 and 10 years. Initial behaviour know of and yet impossible to fully know (Merleau- changes correlated with outcomes 1 to 9 years later. Ponty, 1945/2012). In phenomenology, the lifeworld is Successful weight loss maintenance was associated both the source of and approach to possible experi- with a range of factors and mostly with high levels ences (van Manen, 2014). By taking a phenomenologi- of physical activity, low calorie and fat intake, high cal approach, the current study aims to go beyond the levels of restraint, low levels of disinhibition and self- taken-for-granted and give insight into essential mean- monitoring (weighing) (Thomas et al., 2014). Stubbs ings of long-term weight loss following severe obesity. et al. (2011) maintain that successful weight loss To get to a phenomenon’s meanings, the researcher maintainers settle into a new profile of behaviours, must be attentive and open. Being open to the world attitudes and psychological profiles that essentially as experienced and trying to “bracket” assumptions, lay keep them in a state of vigilance. understandings and scientific explanations are basic Previous qualitative studies on non-surgical weight activities in our approach. These processes lead back loss in overweight and obesity have provided valuable to the phenomenon given in experience (van Manen, insights into weight loss and maintenance. Health-related 2014). To see meanings and distinguish long-term behaviours, barriers and facilitators for weight loss, mean- weight loss after severe obesity from other phenom- ings of identity change and turning points in life have ena, we engaged in reflection and draft writing. been described (Burke, Swigart, Turk, Derro, & Ewing, Getting access to lifeworld dimensions and existential 2009; Byrne, Cooper, & Fairburn, 2003;Epiphaniou& meanings is a challenge, and doing justice to lived Ogden, 2010; Garip & Yardley, 2011; Hindle & Carpenter, experience is a continuing concern throughout the 2011; Lindvall, Larsson, Weinehall, & Emmelin, 2010; research activities (van Manen, 2014). Ogden & Hills, 2008; Ogden, Stavrinaki, & Stubbs, 2009; The group of researchers behind this study com- Sarlio-Lähteenkorva, 2000; Stuckey et al., 2011). However, prises two physiotherapists, one nurse and one clin- losing and maintaining weight from overweight/obesity ical psychologist, all with extensive experience in and losing weight and maintaining weight loss from obesity research, both qualitative and quantitative. severe obesity might be significantly different phenom- We have a particular interest in phenomenology, in ena, and qualitative studies of long-term weight loss existential and situated meanings of weight loss as a maintenance after severe obesity are lacking. Stories of human phenomenon. The point of departure for our people who manage to lose weight and keep it off for the understanding as health care workers is that severe long term after severe obesity exist and are acknowl- obesity can be harmful to an individual’s health and edged, but are presented as exceptional, anecdotal suc- well-being. Severity of weight problems (size, co-mor- cess stories and are not analysed in detail (Freedhoff & bidities) and sustainability of weight loss is important INTERNATIONAL JOURNAL OF QUALITATIVE STUDIES ON HEALTH AND WELL-BEING 3 for health and in clinical encounters, and therefore Table I. Frequency table of participant characteristics. provides an important context for studying successful Descriptor Variable Frequency weight loss. All researchers participated in planning Gender Male 2 the study, read transcripts, engaged in reflective dia- Female 8 logues about materials and contributed to writing this Age 20–30 years 3 article. Three authors (E.N., C.M., M.R.) interviewed 30–40 years 2 40–50 years 4 participants in depth and conducted analyses. The 50–60 years 1 first author conducted five interviews and one fol- low-up interview, practised reflective writing and Highest BMI 35–40 1 drafted this manuscript. 40–45 3 45–50 4 50–60 1 >60 1 Recruitment and participants Current BMI 20–25 1 We sought experiences from persons who previously 25–30 5 had a body weight categorized as severe obesity 30–35 1 35–40 3 according to Body Mass Index (BMI) and currently had a body weight below severe obesity. People who had Weight reduction % 20–30% 2 30–40% 4 started losing weight at least 5 years prior to the study, 40–50% 4 and who had kept off at least 10% of their initial body Relationship status Married w. children 5 weight for these years got a letter of invitation. People Married 1 Cohabitant w. children 1 who had undergone weight loss surgery were not Cohabitant 1 included. Previously, we have described long-term Single 2 Employment status Full-time employed 6 weight loss after bariatric surgery in several studies Self-employed 1 (Natvik, Gjengedal & Råheim, 2013, Natvik, Gjengedal, Student 1 Sick leave 1 Moltu & Råheim, 2014, 2015). Results of long-term post- Retraining 1 surgery experience studies, in particular that having bariatric surgery involves becoming a patient who Interviews lasted on average 92 minutes, ranging needs medical care and follow-up, spurred interest in from 59 to 124 minutes. We aimed to obtain experi- what long-term weight loss maintenance was like out- ences as lived through, rather than views and ready- side the context of surgery. We recruited participants made opinions (van Manen, 2014). To create an with the assistance of experienced family physicians and atmosphere for attentive and open dialogues about weight loss experts in well-established commercial pro- what it is like to lose weight and maintain weight loss grammes. Ten people volunteered to participate. They for the long term, participant and interviewer agreed were 8 women and 2 men aged between 27 and 59 with on a suitable interview setting. We used a quiet space a median age of 37. The sampling strategy in this study where interruptions could be avoided. Some preferred is thus purposive (Malterud, 2001). The number and to be interviewed in a meeting room close to where variation of participants was sufficient to produce a they live or work, and others invited the interviewer rich experiential material (van Manen, 2014). Table I into their homes. presents the characteristic of the participant group. Interviews began by breaking the ice, making space and taking place; for example, by finding a Ethical considerations good way to sit, getting coffee and so on. The inter- viewer repeated the purpose and our interest in The Norwegian Committee of Ethics in Medicine what it is like to engage in weight loss and weight approved the study, and the protocol was registered loss maintenance for years after severe obesity. To at the Social Science Data Service. Participants got make participants familiar with the interview situa- written information about the study, its background, tion and get contact, the researcher began each aims and specific information about interviews. We interview by collecting background information on underscored voluntarily participation and guaranteed age, education, employment and family situation, participants’ anonymity. Information was given by current weight, height and weight loss. Following letter and telephone, and repeated in interviews. this introduction, interviews centred on five topics: (a) The personal weight-journey; (b) Own body; (c) Conducting interviews Habits and practices to maintain current weight; (d) Social life; and (e) Health and a good life. We intro- We conducted 10 in-depth interviews and 1 follow-up duced each topic with a broad question, such as interview with a participant whom we asked to ela- “Can you tell about your weight changes throughout borate the first interview. All interviews were audio- life until today?” recorded and transcribed verbatim for analyses. 4 E. NATVIK ET AL. Aiming for concrete and detailed experiential are mutually related and interconnected. We chose to use descriptions, we prepared questions to get closer to participants’ experiential descriptions (quotes) in the sub- particular events and situations, such as “Has your themes, titled: “self-driven, but not alone—a transformed weight at any point been a threat your situation? Do relationship to self and others”, “still different—joining you remember a particular event? Can you give an new communities”, “distrusting one's own body—build- example?” Most participants talked about their weight ing systems and structures to lean on”,and “interrupted”. loss processes in response to open questions. Before summing up the main dimensions in the conversa- tion, the interviewer asked, “What do you think about Findings the future?” Furthermore, participants were invited to A never-ending story add or deepen anything they felt like sharing about their weight journey, body weight and own body. Lasting weight loss was the only way to get a second The participants grasped this opportunity to talk chance at life after severe obesity—a life the partici- about weight loss experiences, and follow-up questions pants found worth living. A resilient decision to con- were not always needed. As there is a cultural interest in quer one’s own weight issues was essential for weight loss and strategies, healthy habits and practices, establishing a profound lifestyle change. Deciding we concentrated on experiential accounts. We prepared for lasting change meant so much more than making to facilitate concrete and detailed descriptions and not healthy choices and standing firm. Rather, it was a to encourage stories told several times before. watershed moment in life. A deeply personal, percep- Preparations were useful in the interviews and were tive and existential realization about one’s own situa- central to obtaining sufficiently rich experiential mate- tion and related to body weight. The large and heavy rial. In-depth interviews provided possible experiences body no longer complied with a good life, nor had it of weight loss for us to reflect on, interpret and write done for a long time. Deciding to do something about from (van Manen, 2014). it implied an ongoing engagement and commitment to changes—a sense of being fully immersed in pro- found change. Enduring changes. Incorporating Analysis changes. Adjusting changes. Participants put the deci- Analysis was inspired by phenomenological metho- sion to change at the very foreground of life itself, dology as described by van Manen (1997, 2014). rather than it being one of many projects. Researchers read transcripts, wrote reflective notes Losing and keeping weight off for the long term and engaged in reflective dialogues about each inter- was a challenge requiring continuous attention and view and the whole material. We aimed to grasp and efforts. Losing weight implied rethinking meaningful describe a core meaning, an essential structure of aspects of life—relationships, one's own body, emo- sustained weight loss after severe obesity. Reflective tional life and personal values. Weight loss and weight dialogues included searching for and creating eidetic loss maintenance were an epochal change. Sustained phrasings to capture and express the heart of the weight loss had no endpoint, yet was always easy to phenomenon. This way of approaching the textual end. When following severe obesity, sustained weight material is termed holistic reading (van Manen, loss was a never-ending story. 2014). “Terminable and interminable”, reflecting a Five years into a stable, lower weight, a strong process ever vulnerable to being brought to halt, sense of not having got there still prevailed. Lifestyle but that at the same time could never end, captured changes were continuous, absorbing and touched the the eidetic meaning of the text as a whole, and an core of the participants’ being. After at least 5 years of “essential phrasing” to continue our analysis from. living through severe weight issues, profound lifestyle The first author continued the analysis by reading changes and sustained weight loss, participants still reflective notes already produced, rereading each inter- kept forcing themselves to continue recreating and view and writing drafts. Interviews were reread with inter- renewing their ways of living healthily. This constant est in particularly striking expressions and statements labour inevitably affected personal identity. about losing weight for the long term and bearing the Securing weight loss implied a heightened sensi- essential phrasing in mind. Moving back and forth tivity towards oneself and others. Maintenance between writing, rereading transcripts, reflective dialo- involved being alert, thinking and acting to overcome gues about the material and rewriting, themes started a multitude of challenges. Emotions, habits, urges and to emerge. The themes constitute the meaning structure temptations could all threaten weight loss. Sensitivity of engaging in long-term weight loss after severe obesity, following weight loss typically allowed opening up, and consist of one essential and four related subthemes. establishing or sustaining relationships to oneself and “Never-ending story” expresses the most abstracted level others. For the formerly large people, the life they had of analysis of which the subthemes describe nuances and longed for became possible and real. This was a para- variations of losing weight and keeping it off. All themes dox. Committing to change was very much a lone INTERNATIONAL JOURNAL OF QUALITATIVE STUDIES ON HEALTH AND WELL-BEING 5 commitment to oneself, yet being successful inevita- have not arrived at the same time, to put it that way. It lingers a little. Not that I stand in front of the bly involved others. Other people might both help camera that often, but what more can I say? [Short and threaten the process. Family and friends, work- pause]. After all that exercise, I feel fit [short pause]. places and health care professionals being able to . . . When I have lost weight, I can see it. I mean, it adjust or refrain from jeopardizing the weight loss might not be there, but I see it. At least I feel that I process played a crucial role in long-term weight can see it in the mirror. If I have had a hard time, I think I can see that in the mirror too. It is as if I can loss and change. Long-term weight loss presupposed see all the faults in difficult times. When things are a commitment to making changes. To endure, refine going well, I see all good things . . . but mostly the and make new changes, and always by keeping the negative in times of difficulty. . . . It is as if I have no starting point in mind. To leave severe obesity forever, worries when things go [well]. It’s like being on a the formerly large body and life could not fully be left. wave, and that’s what I was, at least for three years. Just a flow of uplifting things kept happening to me. Weight loss involved reflecting on past and present Self-driven, but not alone—a transformed situation, practising new ways of living and incorpor- relationship to self and others ating a wide variety of emotions. Self-awareness now Deciding to lose weight for the long term was a implied a growing and personal sense of emotions. meaningful and deeply personal turning point. The Participants were ambivalent to emotional aspects of decision was pivotal for staying in and recommitting weight loss and were careful of going too deeply into to pervasive and encompassing change every day for problematic experiences. Difficult emotions might dis- 5 years or more. Weight loss processes were highly turb a process they needed to continue. Participants self-driven. Most participants only told others about balanced the amount of painful emotions allowed the decision when they felt more secure that they into the process with the need to do what long- would carry on with it, when the decision had turned term weight loss demanded: into successful action. One woman, who was a former I think I missed a lot during the process. I didn’t take athlete, said: time to notice what I felt. It was just a joyride . . .. Back then, I was “Bea” in the middle of a huge and success- One day, I thought [stops]. I was going to watch a ful super project and everything was awesome. I hockey game in a city nearby. We parked at the bot- didn’t need anything else. I was on top of the world tom of the hill, you know, down by the [stops]. It’sa . . .. Being me now is this process of trying to build a quite steep uphill to the ice arena. I couldn’tkeep up new identity. That’s what I need to do. I’m no longer with the others up that hill, and [thought], “Icannot that big, fat person. This has to do with seeing myself live like this, I must do something. I’m going to work as [stops]. However, I’m always reminded [about the a health care professional, which is quite a physical past]. Yet I don’t want to forget about it either, job.” . . . They [at home] did not really believe in me. I right? It is part of me. went for a walk with my mother. I guess I had been on the weight loss programme for a year. I had started Having experienced what being (too) large means noticing my clothes becoming too big, so I said, “Now, I must start getting rid of my clothes. I’ll go home and seemed to add existential quality to weight loss. clear my closet.” Then she said to me, probably with- Insights connected to previous life intertwined with out thinking, “Well now, there is no point in getting rid the present. A space for feelings cleared. Sadness, of any clothes, soon you will need them again. You’ll anger, self-compassion, warmth and generosity towards put the weight back on when you have finished the oneself and the large body gone were allowed their course.” . . .. I really had to show them. presence: Profound life changes aiming at long-term weight loss maintenance was a complex journey. Always being I was very large, and I didn’t have any thoughts about starting a family, or finding a boyfriend. Which really self-aware, self-observing and ready to adjust. was [what I wanted]. In the end, I just dropped it. Although the large body was history, it lingered in Being so large, I couldn’t think about that at all. In a awareness. Accepting the large body that one used to way, I lost [stops]. Having children was nothing to be was significant in embodying weight loss, making think about at that time, but when things [lifestyle changes and continuing them. Losing weight and change] started to work out, I got hope. . . . I often think about it, and almost have to pinch my arm, “Is maintaining it over time entailed a new relationship this me?” So much has happened in the years after I to different aspects of oneself simultaneously. The finished [the weight loss programme]. . . . It didn’t take new self, the old self, and the image that presented long before I started trying to find a boyfriend and itself in the mirror. One man, who had lost 100 kilos, moving on. It feels as a long time ago, even if it has said: not gone that many years [clearing throat]. So many good things have happened afterwards. From [clear- It lasts for a long time, that I have been [short pause] ing throat] feeling so low back then, to how I feel very much larger. I guess I don’t have the complete now. That’s my motivation for not putting weight picture [short pause]. My body image is not fully back on. updated [short pause]. My body weight and -image 6 E. NATVIK ET AL. Weight loss had opened the participants’ lives up for To understand oneself in new and meaningful ways other people, which was a gain. Others were crucial in was clarifying. To lose weight and keep it off through maintaining the process. Although changes were self-driven efforts and change evoked a sense of per- highly and primarily self-driven, continuing support sonal strength and self-confidence. Embracing new was essential. Participants needed to be surrounded ways of living, feeling healthier and happier became by others who were willing to adjust to create and live something worth sharing. Five years into successful a totally changed life. They had experienced family, weight loss processes, relationships were a topic for friends and colleagues changing or continuing as all participants. Engaging in a close relationship, or before, acting rather indifferently or positive and longing for someone to love. Some relationships had patiently: grown deeper, and some were lost. My husband is slim and can eat all he likes, so it was a bit difficult for him to start this [process] and under- Still different—joining new communities stand it. I started, we made a plan for how to do it, and that made it easier for him. He started to under- Life after severe obesity had to be lived quite differ- stand and saw the results. He says that I’m a different ently compared to the lives of people who were not person now. More present, more awake and wanting to do things. Yet it’s difficult for me to describe how leaving severe obesity. Losing weight meant coming hard it really is. closer to “the ordinary” with regard to body size, but remaining different in important ways. Strong com- Employers who understood and supported the weight mitment to diet and exercise on a daily basis for years loss processes meant a lot. They made it possible for is a certain way of life. To avoid regain, participants participants to combine working-life and “weight-life”. continued thoughtful planning and were much less Participants deeply appreciated health care profes- flexible to enjoy life in unreflected and spontaneous sionals cheering when achieving goals and successes. ways, which is remarkably different from how most People who kept on encouraging them while encoun- people live. Navigating the modern western culture of tering hindrances or suffering defeats. Not all people plenty of food and easy access with stamina, control understood what living with major weight loss meant and moderation was an extremely hard task. and involved for the one leaving severe obesity. There Succeeding to lose weight and live healthily and con- was an impression that some might find major trolled in the long run was personally and socially changes leading away from weight problems hard to prestigious: comprehend and tolerate: It’s difficult with food. I’ve had to look into what my Many did not understand the change at all . . . . I had problem with eating and weight is, and that’s sweets. to explain myself, and of course, when I turned down I never ate too much. I eat a normal dinner, or maybe invitations five times in a row, I didn’t get the sixth less but I can start snacking right afterwards. I can eat one. It’s a bit like that [laughs]. They have accepted it, at least the same amount of calories when snacking. I and I hope they can see why I have made these can have it, even when I feel full. For me, the problem choices. . . . They [friends] are not large, just a little is the cravings for sweets and the energy boost that I round and have tried exercise, but didn’t make it. I feel in my head. . . . So [sigh]. All the time I’ve been feel that they were never happy for my success; no like “Why? Why is it like this? Why, why can’t I eat one ever said anything like “You made it.” . . . I didn’t normally”? Underlying emotional stuff started the get much understanding, and I needed to talk to my whole thing [severe obesity]. But I found a way to supporting team [local nurses, GP, family]. They gave tackle it physically, by eating differently. Then I can’t me the understanding I needed. eat stuff making my blood sugar fluctuate. I can’t eat that anymore, because I get that physical reaction. I Weight loss and lifestyle change could reconnect the need to eat a special and different diet to keep my previously large person and the social world, in that blood sugar stable. I can do that, even if it is a lot of [short pause]. It’s a little tricky. It’s fine when I’mat they increasingly trusted and reached out to each home, but the world is not set up for my way of other. But lifestyle changes could be all-consuming. living. Concentrating on weight loss could come between the person and other people, and not committing to To restore normality with regard to body size, partici- relationships resulted: pants had committed to a life of difference. Different habits, food routines and exercise gave an outsider I don’t go out, I work a lot and I exercise. At one position to social life. Being different like this point, I would like to find someone to share my life appeared as admirable or enviable to others. Not with, but I have no hurry. I’m fine the way things are worrisome, condemnable or disgusting as they had right now. I live the life I want to live. My focus is on lots of exercise, competitions and races. But suddenly experienced that the large body had been. That is, it might happen. This has to do with everything going weight loss and change gave new and meaningful on right now. But on New Year’s Eve, I will probably opportunities to engage with the social world. Yet think “Why don’t I have someone to celebrate with?” valuable encounters with others were at stake in the INTERNATIONAL JOURNAL OF QUALITATIVE STUDIES ON HEALTH AND WELL-BEING 7 continuous worry about regain. Weight regain meant wider popular culture. In this light, the participants losing exactly this newly found and deeply important accomplishing weight loss and a healthy lifestyle for social potential. Living differently remained very life expressed one of the glories of the modern wes- challenging. tern world. Through long-term weight loss after Finding others or communities who valued and severe obesity, they expressed a unique mastery of a shared similar lifestyle commitments became impor- special body of knowledge: tant. Most participants had built a range of new rela- The [lifestyle] changes are only positive for me, and I tionships with people who shared their interests. They am very engaged in it. Change has done me so joined others who were, for example, developing [much] good, and so I would like to engage other cooking skills, carrying out a low carbohydrate diet people. I try to spread a little healthiness [laughs]. I try or practising vigorous exercise for competitions: to motivate people to get up from the couch. Many have asked me for advice on food and eating, I lost my friends when I went into this bubble [life- because they can see what I have done. I like to talk style change] and became rather asocial. I could no about it. longer join in. Or maybe I could, but in my situation, I couldn’t take part in girls’ nights or enjoying myself Participants had started seeing others struggling with like that. I knew I needed to sleep a lot to be ready for severe obesity. Seeing people striving against severe exercise next day. I needed to focus on that. I realize obesity touched them, and echoed their own pro- that I almost only have older friends in my life after I made the changes. Friends aged 35 and up, because cesses. They wanted to help, and expressed a sincere they are in the age of crisis and need to start exercis- enthusiasm to share, include and support others in ing [laughing]. I hang out with them now [laughs]. I making important life changes. “Lived through” need to be with people who are in the same phase or insights sparked initiative and interest beyond one’s who are more like me now. own process. Most participants wished to work pro- By losing weight, enduring lifestyle change and main- fessionally with lifestyle change, and some taining weight loss, participants stood out from the already did. crowd for other reasons than conquering severe obe- Switching from severe obesity to a healthy and sity and becoming slimmer. In fact, they managed lighter life was all encompassing and constantly things so many have tried and failed to do. Life after ongoing. In social life, participants experienced that severe obesity demanded being constantly alert, stay- profound change seemed to act as reappearance and ing on track and protecting oneself from the sur- restoration of human dignity and moral life. roundings. The culture of always-present food, easy Concentrating on weight, diet and exercise for the access to plenty of snacks and great opportunities to long term was imperative to escape severe obesity, stay inactive demanded steady navigation. The cul- but risks followed. New structures could turn into tural push towards weight gain has made it a phe- obsession, illness or total exhaustion. To stay at a nomenon to which many adults can relate. The normal weight, everyday life had to be structured participants and their achievements were rather and lived differently. Different from the previous life unique and attracted others’ attention and admira- and from the lives of many others, yet balancing not tion. Such surroundings played a part in evoking too far away from the norm. memories of what life used to be like: I’m into running, cycling, triathlon and big races. I’m on that wave, and I need to lose a few kilos to Distrusting one’s own body—building systems become better at that. . . . I still work on how others and structures to lean on outside my home [laughs] see me. I have some issues. I have stretch marks and still a flabby stomach. I have Experiences of being large motivated and forced something to work on, but it is not like before. Back change, and led to a healthy and carefully planned then, I waited until everybody else had finished in the structure in everyday life. Monitoring and weight con- public shower before I finally could enter. I use public trol had become unavoidable. Establishing objective showers now, but I am not standing in the middle of the room towelling myself dry. checkpoints in everyday life and sticking to them over time was important for building a structure to lean on, According to participants, body weight rarely came such as weighing oneself, measuring food portions up in conversations while they were large. Others sizes, carefully considering daily amounts of carbohy- used to meet their excess weight and problems drates, proteins and fat and calculating energy expen- attached with silence. After weight loss, body weight diture. Participants checked up on themselves and reappeared as an inevitable and very interesting topic. created predictability in their lives in different ways, Problematic weight—for example, weight cycling— but their strategies always involved a personal struc- remained silent. Weight gain has become a topic of ture for food and exercise, even 5 years or more into debate among lay people, public health advocates stable lower weight: and health care providers, in politics and in the 8 E. NATVIK ET AL. I get up early in the morning, and have oatmeal yourself. I knew what was good enough and what porridge for breakfast. I often use the kitchen scales wasn’t. I’m not afraid of being breathless. You can and portion out, to check the amount. We are lucky always push a little harder when exercising. A work- to have a canteen at work, and I eat salad. Every out is not 15 minutes, but 1 hour, 1 hour and a half. I Friday, I have some cheese and pasta in my salad. remember how soon I felt fit again, not comparing It’s a celebration, and I look forward to it. We have myself with others, but for myself, I was fit. My goal is ordinary dinners, typically spaghetti, chicken or fish, to run a marathon and weigh 72 kilogrammes. and we weigh it. I sleep for half an hour before I Targeting goals, moving forward, pushing the body exercise. Spinning, jogging, swimming or strength and exceeding personal limits was rewarding and training; I exercise every day and extra on the week- ends; 2-hour workouts or hiking in the mountains on satisfying, but gave little space for reflection. Saturdays and Sundays. We always have a meal in the Participants mobilized different personal resources. evening. Sadness, exhaustion, loneliness and despair were part of the process, but not necessarily dwelled on. Self-monitoring had become part of the participants’ Participants seemed to suppress feelings related to everyday lives, and created both confidence and a resignation, but their own body’s fragility was inevi- certain pressure. Participants varied in what actions tably present. Identifying with the large body (gone) they emphasized to keep and to keep on with seemed to bridge past and present self- changes. Some concentrated fully on specific goals understanding. ahead, typically oriented towards physical activity and competitions: In the beginning of the process, I kept thinking, “Why Interrupted haven’t I always done this?” I’m competitive and very Five years of lifestyle change involved holidays, illness, stubborn, and I like to do it this way: “From now, I will do this for 100 days in a row.” So [breathing out], I was injuries, childbirth and other life events. Life events driven by an intense chasing of not having calendar gaps forced pauses or required adjustments in well-con- . . . and I was largely going on the autopilot. I felt very trolled eating practices and exercise. For persons restless coming home from work, with many hours left who had overcome severe obesity, holidays and before bedtime. I had [strong emphasis] to do something. other extraordinary periods occasionally interrupting their new, healthy and preferred ways of living were The strategy of making one’s body able to move and troublesome. On this matter, participants expressed perform, and in that sense become its own asset for ambivalence. Temporarily cutting some slack regard- weight control, was essential. Exploring and taking ing weight and ways of life was unavoidable in the advantage of one’s own bodily potential and capabil- long term. Cutting slack inescapably led to rapid ity connected to joy, strength and invincibility. weight gain. Setbacks demanded strong efforts and Experiencing their own bodies as capable and fit caused profound worry. Participants needed to work gave the participants access to new social spaces hard to get back into routine and structure. Losing and physical activities—and courage to enter and regained weight was a struggle. On the other side, take part. This contrasted social, emotional and prac- temporary attempts to “let go” seemed to play an tical hindrances attached to the large body. important role in negotiating degrees of freedom. Performances and achievements related to physical Testing limits, particularly with regard to eating, was activity strengthened participants’ confidence in part of long-term weight loss maintenance after themselves as bodily beings. Nevertheless, experience severe obesity. Yet, participants needed to conquer with severe obesity and failed attempts to lose weight severe obesity forever. Gaining weight might put the meant that the body could not be trusted. The body whole process at risk. Pleasures of freedom were not needed to be controlled. In this sense, lifestyle change worth weight regain, according to participants’ and weight control became bodily performance and experience: vice versa. Meanings attached to one’s own body changed dramatically with weight loss, performance I admit that I panicked [with emphasis] when step- and conquering new fields: ping on the scales after Christmas. I had gained so much in such a short while; I was frantic [with empha- I exercise a lot and participate in Triathlons and so on. sis]. I did not want to do it anymore, right. It was just I need to lose a few more kilos to improve. I actually fine going back to normal eating. Not eating carbo- beat my physician in a cycling race [laughs]. . . . It’sa hydrates has become normal for me now, although I little funny, because I was always the biggest, but at sometimes eat some of it. . . . I had to sort out what the same time the best girl in many sports during was me. What did I do for others, how did I function? childhood. I was always very active, never at home . . . Everything that I did is what I planned to do. I have . I knew what I could do. I knew the difference done my best, and when I have failed, it’s ok. I’ma between a stroll in the park and pacing yourself so human being. However, that’s no excuse to let every- hard uphill, lying on the ground and barely able to thing go and just let it slide . . . . I’m allowed to be a talk to anyone. Not everyone knows how to exhaust human being. If I eat a slice of cake, everything is not INTERNATIONAL JOURNAL OF QUALITATIVE STUDIES ON HEALTH AND WELL-BEING 9 messed up. I just have to get back on track right Thoughts, emotions and material qualities of the away. body are inseparable, and always connect with the social world (Merleau-Ponty, 1945/2012). Feelings, Continuing the process of weight loss was personally thoughts, actions and encounters with others begin and existentially valuable. Participants dreaded any with the body, express the body, and carry meanings. prospect of it ending. Pleasant experiences, such as Bodily and subjective identity are inseparable, and indulging in a full traditional celebration of Christmas, lived body expresses this ambiguity or double status eventually end. Participants expressed that returning of the body. The lived body is both experiential and to previous pleasures might not be that enjoyable or our expression to the world, showing personal style, important. Interruptions like a traditional celebration mood, emotions and intentions, as well as more seemed to clarify the personal life changing process objective bodily states, such as gender, ethnicity and and meanings attached. Having faith in the process body size. In the everyday experience of a healthy and living slightly relaxed was possible and to some body, the subjective and objective aspects are in extent necessary. Participants were always accompa- agreement, and the lived body remains background nied by high risk of relapse and regain. The thought of (Carel, 2008). returning to severe obesity was intolerable, yet it was In our findings, the changing body and continued extremely easy to slip: weight loss seem incompatible with the sponta- neous and taken-for-granted body, and the objecti- I fractured my leg a year ago, and have had low back pain and a painful knee. I could barely walk for four fied body is insufficient to contain the full process of months, and needed crutches to move. I became very change. Keeping weight off and practising healthy inactive and gained a few kilos. I caught myself think- eating and exercise was crucial, but never enough. A ing that my weight might rise, although I have structural change of the lived body, in how the decided that it’s never [with emphasis] going to hap- participants experienced, responded and acted in pen. It was a bad time. I was terribly bored and it was a hard testing on my patience. I just missed walking everyday life, was central to the phenomenon. This [with emphasis], moving my body, and to do what- means that participants incorporated bodily changes ever I wanted to. . . . I tried to continue, went to the and the ongoing changes to maintain weight, albeit gym every day, but it was a struggle. I have a new not by an instrumentalist approach: their journeys lifestyle, which I really enjoy, and [when injured] it seemed like the people they had become. In this was taken away from me. incorporated being, recognition and awareness of Leaving severe obesity demanded effort and thought- the material reality of one’s own body was para- fulness through and through. Following severe obe- mount. Importantly, this materiality was inseparable sity, long-term weight loss was expressed as a success. from other aspects of one’s being, such as values Participants incorporated being successful through and identity, relationships and sociality, longings profound change. Sustained weight loss after severe and suffering. The objective and subjective body obesity meant a never-ending story. In that sense, coexisted in the weight loss maintenance processes losing weight for the long term implied a turning after severe obesity. In this respect, weight loss point, making and living with profound changes, maintenance is importantly different from an illness and never stopping to do so: experience. Illness experience involves a split between thesubjectiveand objectivebody, andis It is a lifelong project, and I think about it all the time. often connected to alienation (Carel, 2008; There is no fear of going back where I was, because I Svenaeus, 2000;Toombs, 1993). am so determined that it’s not going to happen. Losing weight and keeping it off after severe obesity Nevertheless, I think about it all the time . . . . It feels like a job in which I cannot have a break. seem to have more in common with the philosophy of the recovery tradition in the field of mental health. Personal recovery, in their usage, is defined as “a deeply personal, unique process of changing one’s attitudes, Discussion values, feelings, goals, skills and/or role“ (Anthony, 1993, p. 15), in finding meaningful ways to live with challenges Losing weight and maintaining weight loss after severe rather than aiming to get rid of them. However, defining obesity had become the foreground in life for the peo- personally meaningful ways to live with challenges pre- ple who had decided to go through with it. Self-driven supposes a certain degree of autonomy. changes and actions provided and secured weight loss, Greaves, Poltawski, Garside, and Briscoe (2017) and were intensely meaningful and challenging for the synthesized the results from 26 qualitative studies of participants to continue. The process incorporated their weight loss maintenance, including participants who intentions, projects and interconnection with other peo- had undergone weight loss surgery, who worked on ple and the surrounding world. Carrying out and main- non-surgical weight loss strategies, who were both taining weight loss after severe obesity was a profound, successful and unsuccessful at maintaining weight bodily and existential experience. 10 E. NATVIK ET AL. loss. Weight loss magnitude and stability over time in Greaves et al. (2017), regainers had more of a tension- varied across the 710 participants, suggesting they release structure with micro-endpoints attained and lost, analysed a cluster of phenomena out of which the whereas maintainers saw the needed changes as their phenomenon we have studied might be one. Building new being as people. Changes that would never end their resulting model around constant cognitive and because they would become them. behavioural control of tension, Greaves and collea- Indeed, when moving from knowing what was gues suggested some differences between people good for them to doing it, the participants in the who regain and people who maintain with regard to current study drew on common weight loss strategies, identity and temporality. They reported that weight but importantly not as if they took part in a lifestyle loss maintenance constituted a “constant battle” programme that health professionals or lifestyle (Greaves et al., 2017, p. 151). Weight loss maintenance experts had planned for them and whose goals they entailed going beyond resistance and tensions and adapted. The participants were not primarily subject taking action to reduce or eliminate them, whereas to an intervention or institution. Rather, they incorpo- weight regain seemed connected to handling weight rated weight loss as they had incorporated their loss behaviours as temporary measures (p. 155). excess weight. Painful obesity-related issues and long- Discussing this difference, the authors indicated a ing for a better life had pushed participants towards process of evolution into a new person for those dramatic life changes and altering their own bodies. who maintain weight, with a different outlook, social Initiating and living through weight loss made them life, priorities, leisure pursuits and career (p. 156). Our explicitly aware of themselves as bodily subjects. The study allows for a thorough analysis of this particular current study points to the existential domain, and phenomenon, echoing Greaves and colleagues’ that processes needed to change lifestyle and lose results and elaborating on the process of change weight for the long term are deeply personal. The beyond habits, behaviours and lifestyles (Greaves commitment to living a changed life was a decision et al., 2017). of the self, and an autonomous commitment to one’s Continuing the line of thought stemming from auton- own life. omy and personal recovery, our findings echo results from a qualitative study investigating women’sexperi- Methodological considerations ences of falling ill with fibromyalgia, being in recovery and staying healthy (Grape, Solbrække, Kirkevold, & Starting from the lifeworld, we have presented a Mengshoel, 2015). After fibromyalgia, being healthy context-sensitive and meaning-oriented description demanded major and constant efforts to maintain the of sustained weight loss after severe obesity. In body and profound changes in everyday life. Ongoing phenomenological research, validity is associated bodily awareness, analysing bodily signals, eating health- with the originality of insights and the quality of ily and balancing exercise and relaxation was necessary the analytic processes shown in the study (van to avoid illness. According to Grape and colleagues’ find- Manen, 2014). Furthermore, validity relates to the ings, following fibromyalgia, life will never be the same, questions asked, the support of participants in even after recovery (Grape et al., 2015). returning to their experiences, understanding the In traditions such as the field of mental health and difference between content, meanings and the fibromyalgia, where shadows of health challenges often meaning structure of a phenomenon (van demand lifelong adjustment, recovery traditions building Wijngaarden, van Der Meide, & Dahlberg, 2017). on meaning creation, identity and values have been We hold that our findings are strong, and the ana- developed over years. However, the dominant scientific lysis of underlying meaning structures of weight loss perspective on obesity seems not to capture the existen- is transparent to readers, including participants’ tial, autonomous and personal experience of losing nuanced descriptions. However, meanings are weight and maintaining weight loss emergent in our ambiguous and tentative, leaving this text open for findings. Interventions and measures of effects as solu- appraisal, questioning and expansion. tions to the problem of obesity dominate obesity research. Various forms of restricted diets, increased Note levels of physical activity and strategies from cognitive behavioural therapy are frequent research topics, with 1. Severe obesity is defined as having a Body Mass Index emphasis on weight loss, energy consumption, activity ≥40 or having a BMI ≥ 35 and obesity-related illness levels, biomedical parameters/blood and quality of life. (World Health Organization, 2017b). The inherent epistemology of such interventions is dom- inantly instrumentalist, meaning that the end-point out- Disclosure statement come for a part of the person attains the centre stage. Yet life is not an outcome, it is a process. 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Living a successful weight loss after severe obesity

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Taylor & Francis
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© 2018 The Author(s). Published by Informa UK Limited, trading as Taylor & Francis Group.
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10.1080/17482631.2018.1487762
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INTERNATIONAL JOURNAL OF QUALITATIVE STUDIES ON HEALTH AND WELL-BEING 2018, VOL. 13, 1487762 https://doi.org/10.1080/17482631.2018.1487762 a,b c a,b a,d Eli Natvik , Målfrid Råheim , John Roger Andersen and Christian Moltu a b Department of Health and Caring Sciences, Western Norway University of Applied Sciences, Førde, Norway; Center for Health Research, District General Hospital of Førde, Førde, Norway; Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway; Division of Psychiatry, District General Hospital of Førde, Førde, Norway ABSTRACT ARTICLE HISTORY Accepted 8 June 2018 Purpose: Losing weight and keeping it off for the long term is difficult. Weight regain is common. Experiences of successful non-surgical weight loss after severe obesity are largely KEYWORDS unexplored. We know little about long-term weight loss processes, and how health care Embodiment/bodily services can be of help to those living them. Methods: Drawing on in-depth interviews of 8 experiences; lifestyle change; women and 2 men, the aim of this phenomenological study is to describe the experiences of lived experience; obesity; adults who have been severely obese, who have lost weight and maintained weight loss for phenomenology; well-being the long term (>5 years). Results: Findings show that after severe obesity, sustained weight loss has no endpoint, yet is always easy to end. Keeping weight off means committing to oneself, continuing profound changes and cultivating sensitivity towards oneself and others. A phenomenological understanding of sustained weight loss can inform professionals who deal with health issues and challenges occurring in the life of people leaving severe obesity. From being an unusual condition in the 1970s, the and change, and the risk of enacting stigma and prevalence of severe obesity is increasing in several affecting health negatively. developing countries. If current trends continue, we People’s lived experiences can yield rich examples are facing an epidemic of severe obesity (NCD risk factor to help understand long-term weight loss in concrete collaboration, 2016). Severe obesity is important to ways, and providing an in-depth contextual under- attend to, regarding population health and in clinical standing may guide professional action and encounters. Obesity-related issues may threaten vital life strengthen ethical engagement in clinical encounters functions and limit lifespan. Health risk rises with (Natvik & Moltu, 2016). The aim of the current study increasing body weight, and obesity is related to coron- was to describe lived experiences of adults who have ary heart disease, hypertension, type 2 diabetes, muscu- been severely obese, have lost weight and sustained loskeletal disorders, some cancers, depression and it over a period of at least 5 years. anxiety (National Institute for Health and Care Lifestyle change (diet and exercise modification), Excellence, 2006; National Institutes of Health, 2012; cognitive behavioural therapy, weight loss medica- Prospective Studies Collaboration, 2009;WorldHealth tions and bariatric surgery are treatment strategies Organization, 2017a). Experiences, meanings and atti- for severe obesity (Bray, Frühbeck, Ryan, & Wilding, tudes attached to obesity differ profoundly according to 2016). Weight loss surgery is the most effective inter- severity (Lewis et al., 2010). vention for long-term weight loss, but carries risk of Social stigma, discrimination and withdrawal from mortality, complications and late effects, and health social life and loved ones are consequences for many outcomes are largely unknown (Adams et al., 2012; (Brewis, 2014; Puhl, 2011; Puhl & Heuer, 2009). Weight Colquitt, Pickett, Loveman, & Frampton, 2014; stigma is part of clinical encounters, and health care Puzziferri et al., 2014). Surgery is not an option for providers are not necessarily reflective about this all patients, because of individual preferences—for (Malterud & Ulriksen, 2011; Puhl & Heuer, 2009; example, avoiding risks or advocating fat acceptance Setchell, Gard, Jones, & Watson, 2017). Weight stigma —or societal barriers, such as financial or health sys- in clinical encounters is a paradox, because stigma tem barriers (NCD risk factor collaboration, 2016). affects patients’ health and quality of life negatively, Modest weight loss, 5–10% of initial body weight, is and undermines trust between patients and health sufficient to gain significant health benefits and prevent care providers (Gudzune, Bennett, Cooper, & Bleich, obesity-related illness (Goodpaster et al., 2010;Look 2014; Setchell et al., 2017). This means that health AHEAD Research Group, 2010; Thomas, Bond, Phelan, care providers and patients encounter a tension Hill, & Wing, 2014; Wing & Hill, 2001). Whether modest between supporting initiatives towards weight loss weight loss is experienced as enough may depend on CONTACT Eli Natvik [email protected] Department of Health and Caring Sciences, Western Norway University of Applied Sciences, Førde, Norway © 2018 The Author(s). Published by Informa UK Limited, trading as Taylor & Francis Group. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 2 E. NATVIK ET AL. initial size, weight and health. Non-surgical weight loss Hall, 2016; Marzocchi, Cappellari, Dalle Grave, & initiatives for people suffering from severe obesity typi- Marchesini, 2011;Sharma, 2017). This means that as an cally aim for a loss of 20% or more to achieve health experiential phenomenon, long-term weight loss after benefits (Yumuk et al., 2015). Approximately 20% of severe obesity is largely unexplored. those who obtain weight loss maintain it for one year To gain new insight into sustained non-surgical or longer (Dombrowski, Knittle, Avenell, Araújo-Soares, weight loss after severe obesity, the people who & Sniehotta, 2014; Wing & Phelan, 2005). Many termi- have accomplished this (or not) and their experiential nate weight loss efforts in an early phase, and weight life is an important starting point. Research based in regain is frequent (Christiansen, Bruun, Madsen, & the first-person perspective can deepen current Richelsen, 2007;Knowler et al., 2009;Look AHEAD understandings of and meanings attached to long- Research Group, 2014;Ryanet al., 2010; Thomas et al., term weight loss. Our research question was “What 2014). This means that long-term maintenance of is it like for people with severe obesity to lose weight weight loss via lifestyle changes is possible, but difficult and keep it off for the long-term?” (Frühbeck, Toplak, Woodward, Halford, & Yumuk, 2014; MacLean et al., 2015). Methodology The National Weight Control Registry (NWCR) has identified successful weight loss maintainers and To explore experiences of weight loss, we designed a described their strategies, health behaviours and qualitative study grounded in a phenomenological body weight trajectories since 1993. Participants approach as described by van Manen (2014). Our ambi- with larger initial weight loss have been most success- tion was to understand the ways in which weight loss ful in the long term (Thomas et al., 2014; Wing & following severe obesity incorporates the person’sliv- Phelan, 2005). Successful participants regained more ing. Weight loss is a human phenomenon carrying rapidly, but regained very little after five years, and lifeworld meanings. Lifeworld points to the world of heavier participants followed the same pattern experience, our particular world that we intimately (Thomas et al., 2014). Maintaining weight loss for 2 know and take for granted (Husserl, 1954/1970). years or longer was associated with maintaining larger Ambiguity permeates our lifeworld as it is both all we weight loss at 5 and 10 years. Initial behaviour know of and yet impossible to fully know (Merleau- changes correlated with outcomes 1 to 9 years later. Ponty, 1945/2012). In phenomenology, the lifeworld is Successful weight loss maintenance was associated both the source of and approach to possible experi- with a range of factors and mostly with high levels ences (van Manen, 2014). By taking a phenomenologi- of physical activity, low calorie and fat intake, high cal approach, the current study aims to go beyond the levels of restraint, low levels of disinhibition and self- taken-for-granted and give insight into essential mean- monitoring (weighing) (Thomas et al., 2014). Stubbs ings of long-term weight loss following severe obesity. et al. (2011) maintain that successful weight loss To get to a phenomenon’s meanings, the researcher maintainers settle into a new profile of behaviours, must be attentive and open. Being open to the world attitudes and psychological profiles that essentially as experienced and trying to “bracket” assumptions, lay keep them in a state of vigilance. understandings and scientific explanations are basic Previous qualitative studies on non-surgical weight activities in our approach. These processes lead back loss in overweight and obesity have provided valuable to the phenomenon given in experience (van Manen, insights into weight loss and maintenance. Health-related 2014). To see meanings and distinguish long-term behaviours, barriers and facilitators for weight loss, mean- weight loss after severe obesity from other phenom- ings of identity change and turning points in life have ena, we engaged in reflection and draft writing. been described (Burke, Swigart, Turk, Derro, & Ewing, Getting access to lifeworld dimensions and existential 2009; Byrne, Cooper, & Fairburn, 2003;Epiphaniou& meanings is a challenge, and doing justice to lived Ogden, 2010; Garip & Yardley, 2011; Hindle & Carpenter, experience is a continuing concern throughout the 2011; Lindvall, Larsson, Weinehall, & Emmelin, 2010; research activities (van Manen, 2014). Ogden & Hills, 2008; Ogden, Stavrinaki, & Stubbs, 2009; The group of researchers behind this study com- Sarlio-Lähteenkorva, 2000; Stuckey et al., 2011). However, prises two physiotherapists, one nurse and one clin- losing and maintaining weight from overweight/obesity ical psychologist, all with extensive experience in and losing weight and maintaining weight loss from obesity research, both qualitative and quantitative. severe obesity might be significantly different phenom- We have a particular interest in phenomenology, in ena, and qualitative studies of long-term weight loss existential and situated meanings of weight loss as a maintenance after severe obesity are lacking. Stories of human phenomenon. The point of departure for our people who manage to lose weight and keep it off for the understanding as health care workers is that severe long term after severe obesity exist and are acknowl- obesity can be harmful to an individual’s health and edged, but are presented as exceptional, anecdotal suc- well-being. Severity of weight problems (size, co-mor- cess stories and are not analysed in detail (Freedhoff & bidities) and sustainability of weight loss is important INTERNATIONAL JOURNAL OF QUALITATIVE STUDIES ON HEALTH AND WELL-BEING 3 for health and in clinical encounters, and therefore Table I. Frequency table of participant characteristics. provides an important context for studying successful Descriptor Variable Frequency weight loss. All researchers participated in planning Gender Male 2 the study, read transcripts, engaged in reflective dia- Female 8 logues about materials and contributed to writing this Age 20–30 years 3 article. Three authors (E.N., C.M., M.R.) interviewed 30–40 years 2 40–50 years 4 participants in depth and conducted analyses. The 50–60 years 1 first author conducted five interviews and one fol- low-up interview, practised reflective writing and Highest BMI 35–40 1 drafted this manuscript. 40–45 3 45–50 4 50–60 1 >60 1 Recruitment and participants Current BMI 20–25 1 We sought experiences from persons who previously 25–30 5 had a body weight categorized as severe obesity 30–35 1 35–40 3 according to Body Mass Index (BMI) and currently had a body weight below severe obesity. People who had Weight reduction % 20–30% 2 30–40% 4 started losing weight at least 5 years prior to the study, 40–50% 4 and who had kept off at least 10% of their initial body Relationship status Married w. children 5 weight for these years got a letter of invitation. People Married 1 Cohabitant w. children 1 who had undergone weight loss surgery were not Cohabitant 1 included. Previously, we have described long-term Single 2 Employment status Full-time employed 6 weight loss after bariatric surgery in several studies Self-employed 1 (Natvik, Gjengedal & Råheim, 2013, Natvik, Gjengedal, Student 1 Sick leave 1 Moltu & Råheim, 2014, 2015). Results of long-term post- Retraining 1 surgery experience studies, in particular that having bariatric surgery involves becoming a patient who Interviews lasted on average 92 minutes, ranging needs medical care and follow-up, spurred interest in from 59 to 124 minutes. We aimed to obtain experi- what long-term weight loss maintenance was like out- ences as lived through, rather than views and ready- side the context of surgery. We recruited participants made opinions (van Manen, 2014). To create an with the assistance of experienced family physicians and atmosphere for attentive and open dialogues about weight loss experts in well-established commercial pro- what it is like to lose weight and maintain weight loss grammes. Ten people volunteered to participate. They for the long term, participant and interviewer agreed were 8 women and 2 men aged between 27 and 59 with on a suitable interview setting. We used a quiet space a median age of 37. The sampling strategy in this study where interruptions could be avoided. Some preferred is thus purposive (Malterud, 2001). The number and to be interviewed in a meeting room close to where variation of participants was sufficient to produce a they live or work, and others invited the interviewer rich experiential material (van Manen, 2014). Table I into their homes. presents the characteristic of the participant group. Interviews began by breaking the ice, making space and taking place; for example, by finding a Ethical considerations good way to sit, getting coffee and so on. The inter- viewer repeated the purpose and our interest in The Norwegian Committee of Ethics in Medicine what it is like to engage in weight loss and weight approved the study, and the protocol was registered loss maintenance for years after severe obesity. To at the Social Science Data Service. Participants got make participants familiar with the interview situa- written information about the study, its background, tion and get contact, the researcher began each aims and specific information about interviews. We interview by collecting background information on underscored voluntarily participation and guaranteed age, education, employment and family situation, participants’ anonymity. Information was given by current weight, height and weight loss. Following letter and telephone, and repeated in interviews. this introduction, interviews centred on five topics: (a) The personal weight-journey; (b) Own body; (c) Conducting interviews Habits and practices to maintain current weight; (d) Social life; and (e) Health and a good life. We intro- We conducted 10 in-depth interviews and 1 follow-up duced each topic with a broad question, such as interview with a participant whom we asked to ela- “Can you tell about your weight changes throughout borate the first interview. All interviews were audio- life until today?” recorded and transcribed verbatim for analyses. 4 E. NATVIK ET AL. Aiming for concrete and detailed experiential are mutually related and interconnected. We chose to use descriptions, we prepared questions to get closer to participants’ experiential descriptions (quotes) in the sub- particular events and situations, such as “Has your themes, titled: “self-driven, but not alone—a transformed weight at any point been a threat your situation? Do relationship to self and others”, “still different—joining you remember a particular event? Can you give an new communities”, “distrusting one's own body—build- example?” Most participants talked about their weight ing systems and structures to lean on”,and “interrupted”. loss processes in response to open questions. Before summing up the main dimensions in the conversa- tion, the interviewer asked, “What do you think about Findings the future?” Furthermore, participants were invited to A never-ending story add or deepen anything they felt like sharing about their weight journey, body weight and own body. Lasting weight loss was the only way to get a second The participants grasped this opportunity to talk chance at life after severe obesity—a life the partici- about weight loss experiences, and follow-up questions pants found worth living. A resilient decision to con- were not always needed. As there is a cultural interest in quer one’s own weight issues was essential for weight loss and strategies, healthy habits and practices, establishing a profound lifestyle change. Deciding we concentrated on experiential accounts. We prepared for lasting change meant so much more than making to facilitate concrete and detailed descriptions and not healthy choices and standing firm. Rather, it was a to encourage stories told several times before. watershed moment in life. A deeply personal, percep- Preparations were useful in the interviews and were tive and existential realization about one’s own situa- central to obtaining sufficiently rich experiential mate- tion and related to body weight. The large and heavy rial. In-depth interviews provided possible experiences body no longer complied with a good life, nor had it of weight loss for us to reflect on, interpret and write done for a long time. Deciding to do something about from (van Manen, 2014). it implied an ongoing engagement and commitment to changes—a sense of being fully immersed in pro- found change. Enduring changes. Incorporating Analysis changes. Adjusting changes. Participants put the deci- Analysis was inspired by phenomenological metho- sion to change at the very foreground of life itself, dology as described by van Manen (1997, 2014). rather than it being one of many projects. Researchers read transcripts, wrote reflective notes Losing and keeping weight off for the long term and engaged in reflective dialogues about each inter- was a challenge requiring continuous attention and view and the whole material. We aimed to grasp and efforts. Losing weight implied rethinking meaningful describe a core meaning, an essential structure of aspects of life—relationships, one's own body, emo- sustained weight loss after severe obesity. Reflective tional life and personal values. Weight loss and weight dialogues included searching for and creating eidetic loss maintenance were an epochal change. Sustained phrasings to capture and express the heart of the weight loss had no endpoint, yet was always easy to phenomenon. This way of approaching the textual end. When following severe obesity, sustained weight material is termed holistic reading (van Manen, loss was a never-ending story. 2014). “Terminable and interminable”, reflecting a Five years into a stable, lower weight, a strong process ever vulnerable to being brought to halt, sense of not having got there still prevailed. Lifestyle but that at the same time could never end, captured changes were continuous, absorbing and touched the the eidetic meaning of the text as a whole, and an core of the participants’ being. After at least 5 years of “essential phrasing” to continue our analysis from. living through severe weight issues, profound lifestyle The first author continued the analysis by reading changes and sustained weight loss, participants still reflective notes already produced, rereading each inter- kept forcing themselves to continue recreating and view and writing drafts. Interviews were reread with inter- renewing their ways of living healthily. This constant est in particularly striking expressions and statements labour inevitably affected personal identity. about losing weight for the long term and bearing the Securing weight loss implied a heightened sensi- essential phrasing in mind. Moving back and forth tivity towards oneself and others. Maintenance between writing, rereading transcripts, reflective dialo- involved being alert, thinking and acting to overcome gues about the material and rewriting, themes started a multitude of challenges. Emotions, habits, urges and to emerge. The themes constitute the meaning structure temptations could all threaten weight loss. Sensitivity of engaging in long-term weight loss after severe obesity, following weight loss typically allowed opening up, and consist of one essential and four related subthemes. establishing or sustaining relationships to oneself and “Never-ending story” expresses the most abstracted level others. For the formerly large people, the life they had of analysis of which the subthemes describe nuances and longed for became possible and real. This was a para- variations of losing weight and keeping it off. All themes dox. Committing to change was very much a lone INTERNATIONAL JOURNAL OF QUALITATIVE STUDIES ON HEALTH AND WELL-BEING 5 commitment to oneself, yet being successful inevita- have not arrived at the same time, to put it that way. It lingers a little. Not that I stand in front of the bly involved others. Other people might both help camera that often, but what more can I say? [Short and threaten the process. Family and friends, work- pause]. After all that exercise, I feel fit [short pause]. places and health care professionals being able to . . . When I have lost weight, I can see it. I mean, it adjust or refrain from jeopardizing the weight loss might not be there, but I see it. At least I feel that I process played a crucial role in long-term weight can see it in the mirror. If I have had a hard time, I think I can see that in the mirror too. It is as if I can loss and change. Long-term weight loss presupposed see all the faults in difficult times. When things are a commitment to making changes. To endure, refine going well, I see all good things . . . but mostly the and make new changes, and always by keeping the negative in times of difficulty. . . . It is as if I have no starting point in mind. To leave severe obesity forever, worries when things go [well]. It’s like being on a the formerly large body and life could not fully be left. wave, and that’s what I was, at least for three years. Just a flow of uplifting things kept happening to me. Weight loss involved reflecting on past and present Self-driven, but not alone—a transformed situation, practising new ways of living and incorpor- relationship to self and others ating a wide variety of emotions. Self-awareness now Deciding to lose weight for the long term was a implied a growing and personal sense of emotions. meaningful and deeply personal turning point. The Participants were ambivalent to emotional aspects of decision was pivotal for staying in and recommitting weight loss and were careful of going too deeply into to pervasive and encompassing change every day for problematic experiences. Difficult emotions might dis- 5 years or more. Weight loss processes were highly turb a process they needed to continue. Participants self-driven. Most participants only told others about balanced the amount of painful emotions allowed the decision when they felt more secure that they into the process with the need to do what long- would carry on with it, when the decision had turned term weight loss demanded: into successful action. One woman, who was a former I think I missed a lot during the process. I didn’t take athlete, said: time to notice what I felt. It was just a joyride . . .. Back then, I was “Bea” in the middle of a huge and success- One day, I thought [stops]. I was going to watch a ful super project and everything was awesome. I hockey game in a city nearby. We parked at the bot- didn’t need anything else. I was on top of the world tom of the hill, you know, down by the [stops]. It’sa . . .. Being me now is this process of trying to build a quite steep uphill to the ice arena. I couldn’tkeep up new identity. That’s what I need to do. I’m no longer with the others up that hill, and [thought], “Icannot that big, fat person. This has to do with seeing myself live like this, I must do something. I’m going to work as [stops]. However, I’m always reminded [about the a health care professional, which is quite a physical past]. Yet I don’t want to forget about it either, job.” . . . They [at home] did not really believe in me. I right? It is part of me. went for a walk with my mother. I guess I had been on the weight loss programme for a year. I had started Having experienced what being (too) large means noticing my clothes becoming too big, so I said, “Now, I must start getting rid of my clothes. I’ll go home and seemed to add existential quality to weight loss. clear my closet.” Then she said to me, probably with- Insights connected to previous life intertwined with out thinking, “Well now, there is no point in getting rid the present. A space for feelings cleared. Sadness, of any clothes, soon you will need them again. You’ll anger, self-compassion, warmth and generosity towards put the weight back on when you have finished the oneself and the large body gone were allowed their course.” . . .. I really had to show them. presence: Profound life changes aiming at long-term weight loss maintenance was a complex journey. Always being I was very large, and I didn’t have any thoughts about starting a family, or finding a boyfriend. Which really self-aware, self-observing and ready to adjust. was [what I wanted]. In the end, I just dropped it. Although the large body was history, it lingered in Being so large, I couldn’t think about that at all. In a awareness. Accepting the large body that one used to way, I lost [stops]. Having children was nothing to be was significant in embodying weight loss, making think about at that time, but when things [lifestyle changes and continuing them. Losing weight and change] started to work out, I got hope. . . . I often think about it, and almost have to pinch my arm, “Is maintaining it over time entailed a new relationship this me?” So much has happened in the years after I to different aspects of oneself simultaneously. The finished [the weight loss programme]. . . . It didn’t take new self, the old self, and the image that presented long before I started trying to find a boyfriend and itself in the mirror. One man, who had lost 100 kilos, moving on. It feels as a long time ago, even if it has said: not gone that many years [clearing throat]. So many good things have happened afterwards. From [clear- It lasts for a long time, that I have been [short pause] ing throat] feeling so low back then, to how I feel very much larger. I guess I don’t have the complete now. That’s my motivation for not putting weight picture [short pause]. My body image is not fully back on. updated [short pause]. My body weight and -image 6 E. NATVIK ET AL. Weight loss had opened the participants’ lives up for To understand oneself in new and meaningful ways other people, which was a gain. Others were crucial in was clarifying. To lose weight and keep it off through maintaining the process. Although changes were self-driven efforts and change evoked a sense of per- highly and primarily self-driven, continuing support sonal strength and self-confidence. Embracing new was essential. Participants needed to be surrounded ways of living, feeling healthier and happier became by others who were willing to adjust to create and live something worth sharing. Five years into successful a totally changed life. They had experienced family, weight loss processes, relationships were a topic for friends and colleagues changing or continuing as all participants. Engaging in a close relationship, or before, acting rather indifferently or positive and longing for someone to love. Some relationships had patiently: grown deeper, and some were lost. My husband is slim and can eat all he likes, so it was a bit difficult for him to start this [process] and under- Still different—joining new communities stand it. I started, we made a plan for how to do it, and that made it easier for him. He started to under- Life after severe obesity had to be lived quite differ- stand and saw the results. He says that I’m a different ently compared to the lives of people who were not person now. More present, more awake and wanting to do things. Yet it’s difficult for me to describe how leaving severe obesity. Losing weight meant coming hard it really is. closer to “the ordinary” with regard to body size, but remaining different in important ways. Strong com- Employers who understood and supported the weight mitment to diet and exercise on a daily basis for years loss processes meant a lot. They made it possible for is a certain way of life. To avoid regain, participants participants to combine working-life and “weight-life”. continued thoughtful planning and were much less Participants deeply appreciated health care profes- flexible to enjoy life in unreflected and spontaneous sionals cheering when achieving goals and successes. ways, which is remarkably different from how most People who kept on encouraging them while encoun- people live. Navigating the modern western culture of tering hindrances or suffering defeats. Not all people plenty of food and easy access with stamina, control understood what living with major weight loss meant and moderation was an extremely hard task. and involved for the one leaving severe obesity. There Succeeding to lose weight and live healthily and con- was an impression that some might find major trolled in the long run was personally and socially changes leading away from weight problems hard to prestigious: comprehend and tolerate: It’s difficult with food. I’ve had to look into what my Many did not understand the change at all . . . . I had problem with eating and weight is, and that’s sweets. to explain myself, and of course, when I turned down I never ate too much. I eat a normal dinner, or maybe invitations five times in a row, I didn’t get the sixth less but I can start snacking right afterwards. I can eat one. It’s a bit like that [laughs]. They have accepted it, at least the same amount of calories when snacking. I and I hope they can see why I have made these can have it, even when I feel full. For me, the problem choices. . . . They [friends] are not large, just a little is the cravings for sweets and the energy boost that I round and have tried exercise, but didn’t make it. I feel in my head. . . . So [sigh]. All the time I’ve been feel that they were never happy for my success; no like “Why? Why is it like this? Why, why can’t I eat one ever said anything like “You made it.” . . . I didn’t normally”? Underlying emotional stuff started the get much understanding, and I needed to talk to my whole thing [severe obesity]. But I found a way to supporting team [local nurses, GP, family]. They gave tackle it physically, by eating differently. Then I can’t me the understanding I needed. eat stuff making my blood sugar fluctuate. I can’t eat that anymore, because I get that physical reaction. I Weight loss and lifestyle change could reconnect the need to eat a special and different diet to keep my previously large person and the social world, in that blood sugar stable. I can do that, even if it is a lot of [short pause]. It’s a little tricky. It’s fine when I’mat they increasingly trusted and reached out to each home, but the world is not set up for my way of other. But lifestyle changes could be all-consuming. living. Concentrating on weight loss could come between the person and other people, and not committing to To restore normality with regard to body size, partici- relationships resulted: pants had committed to a life of difference. Different habits, food routines and exercise gave an outsider I don’t go out, I work a lot and I exercise. At one position to social life. Being different like this point, I would like to find someone to share my life appeared as admirable or enviable to others. Not with, but I have no hurry. I’m fine the way things are worrisome, condemnable or disgusting as they had right now. I live the life I want to live. My focus is on lots of exercise, competitions and races. But suddenly experienced that the large body had been. That is, it might happen. This has to do with everything going weight loss and change gave new and meaningful on right now. But on New Year’s Eve, I will probably opportunities to engage with the social world. Yet think “Why don’t I have someone to celebrate with?” valuable encounters with others were at stake in the INTERNATIONAL JOURNAL OF QUALITATIVE STUDIES ON HEALTH AND WELL-BEING 7 continuous worry about regain. Weight regain meant wider popular culture. In this light, the participants losing exactly this newly found and deeply important accomplishing weight loss and a healthy lifestyle for social potential. Living differently remained very life expressed one of the glories of the modern wes- challenging. tern world. Through long-term weight loss after Finding others or communities who valued and severe obesity, they expressed a unique mastery of a shared similar lifestyle commitments became impor- special body of knowledge: tant. Most participants had built a range of new rela- The [lifestyle] changes are only positive for me, and I tionships with people who shared their interests. They am very engaged in it. Change has done me so joined others who were, for example, developing [much] good, and so I would like to engage other cooking skills, carrying out a low carbohydrate diet people. I try to spread a little healthiness [laughs]. I try or practising vigorous exercise for competitions: to motivate people to get up from the couch. Many have asked me for advice on food and eating, I lost my friends when I went into this bubble [life- because they can see what I have done. I like to talk style change] and became rather asocial. I could no about it. longer join in. Or maybe I could, but in my situation, I couldn’t take part in girls’ nights or enjoying myself Participants had started seeing others struggling with like that. I knew I needed to sleep a lot to be ready for severe obesity. Seeing people striving against severe exercise next day. I needed to focus on that. I realize obesity touched them, and echoed their own pro- that I almost only have older friends in my life after I made the changes. Friends aged 35 and up, because cesses. They wanted to help, and expressed a sincere they are in the age of crisis and need to start exercis- enthusiasm to share, include and support others in ing [laughing]. I hang out with them now [laughs]. I making important life changes. “Lived through” need to be with people who are in the same phase or insights sparked initiative and interest beyond one’s who are more like me now. own process. Most participants wished to work pro- By losing weight, enduring lifestyle change and main- fessionally with lifestyle change, and some taining weight loss, participants stood out from the already did. crowd for other reasons than conquering severe obe- Switching from severe obesity to a healthy and sity and becoming slimmer. In fact, they managed lighter life was all encompassing and constantly things so many have tried and failed to do. Life after ongoing. In social life, participants experienced that severe obesity demanded being constantly alert, stay- profound change seemed to act as reappearance and ing on track and protecting oneself from the sur- restoration of human dignity and moral life. roundings. The culture of always-present food, easy Concentrating on weight, diet and exercise for the access to plenty of snacks and great opportunities to long term was imperative to escape severe obesity, stay inactive demanded steady navigation. The cul- but risks followed. New structures could turn into tural push towards weight gain has made it a phe- obsession, illness or total exhaustion. To stay at a nomenon to which many adults can relate. The normal weight, everyday life had to be structured participants and their achievements were rather and lived differently. Different from the previous life unique and attracted others’ attention and admira- and from the lives of many others, yet balancing not tion. Such surroundings played a part in evoking too far away from the norm. memories of what life used to be like: I’m into running, cycling, triathlon and big races. I’m on that wave, and I need to lose a few kilos to Distrusting one’s own body—building systems become better at that. . . . I still work on how others and structures to lean on outside my home [laughs] see me. I have some issues. I have stretch marks and still a flabby stomach. I have Experiences of being large motivated and forced something to work on, but it is not like before. Back change, and led to a healthy and carefully planned then, I waited until everybody else had finished in the structure in everyday life. Monitoring and weight con- public shower before I finally could enter. I use public trol had become unavoidable. Establishing objective showers now, but I am not standing in the middle of the room towelling myself dry. checkpoints in everyday life and sticking to them over time was important for building a structure to lean on, According to participants, body weight rarely came such as weighing oneself, measuring food portions up in conversations while they were large. Others sizes, carefully considering daily amounts of carbohy- used to meet their excess weight and problems drates, proteins and fat and calculating energy expen- attached with silence. After weight loss, body weight diture. Participants checked up on themselves and reappeared as an inevitable and very interesting topic. created predictability in their lives in different ways, Problematic weight—for example, weight cycling— but their strategies always involved a personal struc- remained silent. Weight gain has become a topic of ture for food and exercise, even 5 years or more into debate among lay people, public health advocates stable lower weight: and health care providers, in politics and in the 8 E. NATVIK ET AL. I get up early in the morning, and have oatmeal yourself. I knew what was good enough and what porridge for breakfast. I often use the kitchen scales wasn’t. I’m not afraid of being breathless. You can and portion out, to check the amount. We are lucky always push a little harder when exercising. A work- to have a canteen at work, and I eat salad. Every out is not 15 minutes, but 1 hour, 1 hour and a half. I Friday, I have some cheese and pasta in my salad. remember how soon I felt fit again, not comparing It’s a celebration, and I look forward to it. We have myself with others, but for myself, I was fit. My goal is ordinary dinners, typically spaghetti, chicken or fish, to run a marathon and weigh 72 kilogrammes. and we weigh it. I sleep for half an hour before I Targeting goals, moving forward, pushing the body exercise. Spinning, jogging, swimming or strength and exceeding personal limits was rewarding and training; I exercise every day and extra on the week- ends; 2-hour workouts or hiking in the mountains on satisfying, but gave little space for reflection. Saturdays and Sundays. We always have a meal in the Participants mobilized different personal resources. evening. Sadness, exhaustion, loneliness and despair were part of the process, but not necessarily dwelled on. Self-monitoring had become part of the participants’ Participants seemed to suppress feelings related to everyday lives, and created both confidence and a resignation, but their own body’s fragility was inevi- certain pressure. Participants varied in what actions tably present. Identifying with the large body (gone) they emphasized to keep and to keep on with seemed to bridge past and present self- changes. Some concentrated fully on specific goals understanding. ahead, typically oriented towards physical activity and competitions: In the beginning of the process, I kept thinking, “Why Interrupted haven’t I always done this?” I’m competitive and very Five years of lifestyle change involved holidays, illness, stubborn, and I like to do it this way: “From now, I will do this for 100 days in a row.” So [breathing out], I was injuries, childbirth and other life events. Life events driven by an intense chasing of not having calendar gaps forced pauses or required adjustments in well-con- . . . and I was largely going on the autopilot. I felt very trolled eating practices and exercise. For persons restless coming home from work, with many hours left who had overcome severe obesity, holidays and before bedtime. I had [strong emphasis] to do something. other extraordinary periods occasionally interrupting their new, healthy and preferred ways of living were The strategy of making one’s body able to move and troublesome. On this matter, participants expressed perform, and in that sense become its own asset for ambivalence. Temporarily cutting some slack regard- weight control, was essential. Exploring and taking ing weight and ways of life was unavoidable in the advantage of one’s own bodily potential and capabil- long term. Cutting slack inescapably led to rapid ity connected to joy, strength and invincibility. weight gain. Setbacks demanded strong efforts and Experiencing their own bodies as capable and fit caused profound worry. Participants needed to work gave the participants access to new social spaces hard to get back into routine and structure. Losing and physical activities—and courage to enter and regained weight was a struggle. On the other side, take part. This contrasted social, emotional and prac- temporary attempts to “let go” seemed to play an tical hindrances attached to the large body. important role in negotiating degrees of freedom. Performances and achievements related to physical Testing limits, particularly with regard to eating, was activity strengthened participants’ confidence in part of long-term weight loss maintenance after themselves as bodily beings. Nevertheless, experience severe obesity. Yet, participants needed to conquer with severe obesity and failed attempts to lose weight severe obesity forever. Gaining weight might put the meant that the body could not be trusted. The body whole process at risk. Pleasures of freedom were not needed to be controlled. In this sense, lifestyle change worth weight regain, according to participants’ and weight control became bodily performance and experience: vice versa. Meanings attached to one’s own body changed dramatically with weight loss, performance I admit that I panicked [with emphasis] when step- and conquering new fields: ping on the scales after Christmas. I had gained so much in such a short while; I was frantic [with empha- I exercise a lot and participate in Triathlons and so on. sis]. I did not want to do it anymore, right. It was just I need to lose a few more kilos to improve. I actually fine going back to normal eating. Not eating carbo- beat my physician in a cycling race [laughs]. . . . It’sa hydrates has become normal for me now, although I little funny, because I was always the biggest, but at sometimes eat some of it. . . . I had to sort out what the same time the best girl in many sports during was me. What did I do for others, how did I function? childhood. I was always very active, never at home . . . Everything that I did is what I planned to do. I have . I knew what I could do. I knew the difference done my best, and when I have failed, it’s ok. I’ma between a stroll in the park and pacing yourself so human being. However, that’s no excuse to let every- hard uphill, lying on the ground and barely able to thing go and just let it slide . . . . I’m allowed to be a talk to anyone. Not everyone knows how to exhaust human being. If I eat a slice of cake, everything is not INTERNATIONAL JOURNAL OF QUALITATIVE STUDIES ON HEALTH AND WELL-BEING 9 messed up. I just have to get back on track right Thoughts, emotions and material qualities of the away. body are inseparable, and always connect with the social world (Merleau-Ponty, 1945/2012). Feelings, Continuing the process of weight loss was personally thoughts, actions and encounters with others begin and existentially valuable. Participants dreaded any with the body, express the body, and carry meanings. prospect of it ending. Pleasant experiences, such as Bodily and subjective identity are inseparable, and indulging in a full traditional celebration of Christmas, lived body expresses this ambiguity or double status eventually end. Participants expressed that returning of the body. The lived body is both experiential and to previous pleasures might not be that enjoyable or our expression to the world, showing personal style, important. Interruptions like a traditional celebration mood, emotions and intentions, as well as more seemed to clarify the personal life changing process objective bodily states, such as gender, ethnicity and and meanings attached. Having faith in the process body size. In the everyday experience of a healthy and living slightly relaxed was possible and to some body, the subjective and objective aspects are in extent necessary. Participants were always accompa- agreement, and the lived body remains background nied by high risk of relapse and regain. The thought of (Carel, 2008). returning to severe obesity was intolerable, yet it was In our findings, the changing body and continued extremely easy to slip: weight loss seem incompatible with the sponta- neous and taken-for-granted body, and the objecti- I fractured my leg a year ago, and have had low back pain and a painful knee. I could barely walk for four fied body is insufficient to contain the full process of months, and needed crutches to move. I became very change. Keeping weight off and practising healthy inactive and gained a few kilos. I caught myself think- eating and exercise was crucial, but never enough. A ing that my weight might rise, although I have structural change of the lived body, in how the decided that it’s never [with emphasis] going to hap- participants experienced, responded and acted in pen. It was a bad time. I was terribly bored and it was a hard testing on my patience. I just missed walking everyday life, was central to the phenomenon. This [with emphasis], moving my body, and to do what- means that participants incorporated bodily changes ever I wanted to. . . . I tried to continue, went to the and the ongoing changes to maintain weight, albeit gym every day, but it was a struggle. I have a new not by an instrumentalist approach: their journeys lifestyle, which I really enjoy, and [when injured] it seemed like the people they had become. In this was taken away from me. incorporated being, recognition and awareness of Leaving severe obesity demanded effort and thought- the material reality of one’s own body was para- fulness through and through. Following severe obe- mount. Importantly, this materiality was inseparable sity, long-term weight loss was expressed as a success. from other aspects of one’s being, such as values Participants incorporated being successful through and identity, relationships and sociality, longings profound change. Sustained weight loss after severe and suffering. The objective and subjective body obesity meant a never-ending story. In that sense, coexisted in the weight loss maintenance processes losing weight for the long term implied a turning after severe obesity. In this respect, weight loss point, making and living with profound changes, maintenance is importantly different from an illness and never stopping to do so: experience. Illness experience involves a split between thesubjectiveand objectivebody, andis It is a lifelong project, and I think about it all the time. often connected to alienation (Carel, 2008; There is no fear of going back where I was, because I Svenaeus, 2000;Toombs, 1993). am so determined that it’s not going to happen. Losing weight and keeping it off after severe obesity Nevertheless, I think about it all the time . . . . It feels like a job in which I cannot have a break. seem to have more in common with the philosophy of the recovery tradition in the field of mental health. Personal recovery, in their usage, is defined as “a deeply personal, unique process of changing one’s attitudes, Discussion values, feelings, goals, skills and/or role“ (Anthony, 1993, p. 15), in finding meaningful ways to live with challenges Losing weight and maintaining weight loss after severe rather than aiming to get rid of them. However, defining obesity had become the foreground in life for the peo- personally meaningful ways to live with challenges pre- ple who had decided to go through with it. Self-driven supposes a certain degree of autonomy. changes and actions provided and secured weight loss, Greaves, Poltawski, Garside, and Briscoe (2017) and were intensely meaningful and challenging for the synthesized the results from 26 qualitative studies of participants to continue. The process incorporated their weight loss maintenance, including participants who intentions, projects and interconnection with other peo- had undergone weight loss surgery, who worked on ple and the surrounding world. Carrying out and main- non-surgical weight loss strategies, who were both taining weight loss after severe obesity was a profound, successful and unsuccessful at maintaining weight bodily and existential experience. 10 E. NATVIK ET AL. loss. Weight loss magnitude and stability over time in Greaves et al. (2017), regainers had more of a tension- varied across the 710 participants, suggesting they release structure with micro-endpoints attained and lost, analysed a cluster of phenomena out of which the whereas maintainers saw the needed changes as their phenomenon we have studied might be one. Building new being as people. Changes that would never end their resulting model around constant cognitive and because they would become them. behavioural control of tension, Greaves and collea- Indeed, when moving from knowing what was gues suggested some differences between people good for them to doing it, the participants in the who regain and people who maintain with regard to current study drew on common weight loss strategies, identity and temporality. They reported that weight but importantly not as if they took part in a lifestyle loss maintenance constituted a “constant battle” programme that health professionals or lifestyle (Greaves et al., 2017, p. 151). Weight loss maintenance experts had planned for them and whose goals they entailed going beyond resistance and tensions and adapted. The participants were not primarily subject taking action to reduce or eliminate them, whereas to an intervention or institution. Rather, they incorpo- weight regain seemed connected to handling weight rated weight loss as they had incorporated their loss behaviours as temporary measures (p. 155). excess weight. Painful obesity-related issues and long- Discussing this difference, the authors indicated a ing for a better life had pushed participants towards process of evolution into a new person for those dramatic life changes and altering their own bodies. who maintain weight, with a different outlook, social Initiating and living through weight loss made them life, priorities, leisure pursuits and career (p. 156). Our explicitly aware of themselves as bodily subjects. The study allows for a thorough analysis of this particular current study points to the existential domain, and phenomenon, echoing Greaves and colleagues’ that processes needed to change lifestyle and lose results and elaborating on the process of change weight for the long term are deeply personal. The beyond habits, behaviours and lifestyles (Greaves commitment to living a changed life was a decision et al., 2017). of the self, and an autonomous commitment to one’s Continuing the line of thought stemming from auton- own life. omy and personal recovery, our findings echo results from a qualitative study investigating women’sexperi- Methodological considerations ences of falling ill with fibromyalgia, being in recovery and staying healthy (Grape, Solbrække, Kirkevold, & Starting from the lifeworld, we have presented a Mengshoel, 2015). After fibromyalgia, being healthy context-sensitive and meaning-oriented description demanded major and constant efforts to maintain the of sustained weight loss after severe obesity. In body and profound changes in everyday life. Ongoing phenomenological research, validity is associated bodily awareness, analysing bodily signals, eating health- with the originality of insights and the quality of ily and balancing exercise and relaxation was necessary the analytic processes shown in the study (van to avoid illness. According to Grape and colleagues’ find- Manen, 2014). Furthermore, validity relates to the ings, following fibromyalgia, life will never be the same, questions asked, the support of participants in even after recovery (Grape et al., 2015). returning to their experiences, understanding the In traditions such as the field of mental health and difference between content, meanings and the fibromyalgia, where shadows of health challenges often meaning structure of a phenomenon (van demand lifelong adjustment, recovery traditions building Wijngaarden, van Der Meide, & Dahlberg, 2017). on meaning creation, identity and values have been We hold that our findings are strong, and the ana- developed over years. However, the dominant scientific lysis of underlying meaning structures of weight loss perspective on obesity seems not to capture the existen- is transparent to readers, including participants’ tial, autonomous and personal experience of losing nuanced descriptions. However, meanings are weight and maintaining weight loss emergent in our ambiguous and tentative, leaving this text open for findings. Interventions and measures of effects as solu- appraisal, questioning and expansion. tions to the problem of obesity dominate obesity research. Various forms of restricted diets, increased Note levels of physical activity and strategies from cognitive behavioural therapy are frequent research topics, with 1. Severe obesity is defined as having a Body Mass Index emphasis on weight loss, energy consumption, activity ≥40 or having a BMI ≥ 35 and obesity-related illness levels, biomedical parameters/blood and quality of life. (World Health Organization, 2017b). The inherent epistemology of such interventions is dom- inantly instrumentalist, meaning that the end-point out- Disclosure statement come for a part of the person attains the centre stage. Yet life is not an outcome, it is a process. 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Journal

International Journal of Qualitative Studies on Health and Well-being – Taylor & Francis

Published: Jan 1, 2018

Keywords: Embodiment/bodily experiences; lifestyle change; lived experience; obesity; phenomenology; well-being

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