Older Men’s Experience of Weight Loss and Weight Loss Maintenance Interventions: Qualitative Findings from the Lighten Up Plus Trial

Objectives: We investigate older men’s experiences of weight loss and weight loss maintenance interventions, including commercial slimming clubs and text messaging to encourage regular self-weighing. Study design: A qualitative study using semi-structured interviews nested within a Randomised Controlled Trial (RCT) delivered in the United Kingdom (UK). Methods: Ten semi-structured interviews were completed with male participants who had completed a funded 12 week commercial weight loss programme and opted to receive continued weight management support as part of a subsequent RCT. A topic guide was used to explore attitudes about barriers and facilitators to weight management, experience of attending a commercial weight loss programme, and current strategies for maintenance. Thematic analysis was used with a constant comparison approach. Results: Although there was little apprehension prior to attending commercial weight loss programmes, once present men felt uncomfortable and ostracised for being a minority where content and design was felt to be better suited for female attendees. Text based support was easy to use to prevent weight regain. The texts were generic and men wanted more personalisation. Participants were aware of the wider public health discourse around obesity and felt motivated to use weight management strategies, such as self-weighing, to manage their weight. Nevertheless, men required external support to encourage long term weight management. Conclusion: Overweight and obese older men face potential conflicts when deciding to attend weight loss programmes and the nature of support they wish to receive post attendance. Men did not reject the idea of receiving text messages as a form of support, but felt it distinctly lacked personalisation compared to the face-to-face, weekly, support of being part of a group. The design, delivery and application of text based support to prevent weight regain for overweight and obese men require greater personalisation to provide long term weight management support.


Introduction
In the UK rates of obesity have more than doubled in the last 25 years, and being overweight has become the norm for adults [1]. In 2010, the mean Body Mass Index (BMI) of adults in the UK was 27kg/m 2 , outside the healthy range of 18.5-25kg/m [2]. Nearly a quarter of men and women were obese [3], but men are at a higher risk of overweight and obesity than women [4]. In particular, men have a greater risk of developing diseases associated with obesity, such as coronary heart disease and stroke [5,6]. Despite this greater risk, women continue to show more dissatisfaction with their weight and make continued attempts to alter their lifestyle [7].
Men remain a significant minority when attending weight loss programmes with high levels of attrition [8,9]; only 10% of 29326 referral courses to Weight Watchers by the National Health Service (NHS) were for men [10]. Although literature is limited on men's experiences of attending weight loss programmes [9], many cite that content and promoted weight loss strategies, such as dieting, are better suited to women, while men demonstrate a greater preference to discuss associated health concerns [11]. Several interventions have tried to address male needs [12,13]. The SHED-IT [12] and FFIT [13] programmes were designed for male participants only, delivered in workplaces and football grounds respectively. Whilst many studies have focused on interventions for weight loss, fewer focus on preventing weight regain and supporting weight loss maintenance in the medium to long term [14,15]. A systematic review by Dombrowski et al., concluded interventions targeting diet and physical activity in combination are effective in reducing weight regain after receiving treatment for weight loss at 12 months [16]. Specifically, research has indicated that self-weighing may be a useful method of self-monitoring for both weight loss and maintenance [17,18]. Services have been designed to support men and encourage participation in weight loss maintenance programmes; these include, but not limited to, men only groups, online material, or even pharmacist based services; yet these can be expensive, time consuming or difficult to attend due to employment commitments. A systematic review of the use of text messaging to achieve behaviour change in disease prevention and disease management has reported it as an effective tool for behaviour change [19]. We hypothesised that a technological approach to weight loss maintenance might be attractive to men, as it requires limited time and effort, while messages can prompt self-weighing in privacy as existing literature has shown men to be reluctant to be weighed in front of others owing to stigma [20].
In this study, we discuss findings from semi-structured interviews conducted with older men invited to take part in a text message weight management RCT after attending a commercial weight loss programme for 12-weeks. We focus on content and interactions with group members and facilitators of the commercial sessions, as well as views about the design, delivery and application of a text message maintenance programme that encouraged regular self-weighing. As a result, our findings add to the existing literature on men's weight management, and whether low-cost methods, such as text messaging to promote self-weighing, are acceptable to prevent weight regain following a weight loss programme.

Study design
This is the first qualitative study to explore men's views about commercial weight loss programmes in the UK and the application of text messages to prevent weight regain. Our study design is presented in figure 1. The trial sought to investigate the effectiveness of a 12-week duration weight loss maintenance intervention which used text messaging to encourage self-weighing compared to a brief telephone supported programme with regard to weight change at 9-months. To be eligible participants had to complete a 12-week commercial weight loss programme as part of the Lighten Up weight maintenance service delivered in Birmingham, UK. A summary of the trial and intervention is presented in table 1.

Access and recruitment
Participants who consented to take part in the Lighten Up Plus trial were informed in the participant information leaflet that they might be invited to take part in an interview as part of a research study. Male participants from both arms of the trial were eligible to be interviewed. We focussed on male participants because of the relative lack of qualitative research in men attending commercial weight management programmes. Participants were approached by a researcher (OA) from the University of Birmingham. Written informed consent was taken prior to the interview.

Sampling
Our intention was to generate a sample based on diversity in age, ethnicity, trial arms, and commercial weight loss provider, to understand whether male weight maintenance needs varied according to the aforementioned variables. Our trial recruited a limited number of men (10.3%, which is representative for weight loss/maintenance trials) and only 20% of the sample contained people from Black or Minority Ethnic (BME) backgrounds. Evidence from previous trials has shown lower uptake of weight loss programmes by BME populations. From 39 men taking part in the main trial, 14 gave permission to be contacted about taking part in an interview. Ten provided consent and were interviewed. Therefore, we experienced a high level of non-response. As a result, by using a convenience sampling method [21] devised to seek maximum diversity, we were able to interview a representative sample of men from both trial arms and two members from BME communities. However, our findings are biased towards older men above the age of 40 years and those who attended two prominent commercial weight loss programmes. Details of our sample are presented in table 2.

Data collection
All semi-structured interviews were completed by OA using an interview guide based on a literature review and discussions with the research team (Appendix 1). OA is a male medical professional by background. With reference to literature around men's experiences of weight loss programmes [9,11,22] and interactive weight management interventions [23,24] we designed the interview guide to explore views about commercial weight loss providers, weight management strategies, and lifestyle practices.
Interviews were completed in participant's homes or place that was convenient to participants. Transcription was completed by OA or an external transcription company. All interviews were audio-taped and transcribed verbatim. Interviews ceased when no new concepts/themes were emerging. Participants were informed of their right to withdraw from the study at any time and assured that their personal details would be kept confidential. All participants were given a numerical identifier to ensure anonymity. What is the Lighten Up Plus trial?
Lighten Up Plus was an RCT with participants who completed their initial weight loss programme randomly allocated to one of two weight loss maintenance programmes.
Who was eligible for the Lighten Up Plus trial? Adults aged 18 years or over, who attended a minimum 9 out of 12 weeks of either Weight Watchers, Slimming World or Rosemary Conley, had been objectively weighed within the previous 2 weeks, had access to scales to weigh self, and access to a phone line (mobile or land-line). Those unable to understand English or women known to be pregnant were excluded.
What interventions did the Lighten Up Plus comparison groups receive?
Usual care received a telephone conversation about weight maintenance with a member of the call centre staff plus an information sheet with tips for preventing weight regain. The intervention received usual care plus weekly text messages (for 3 months) asking adults to self-weigh, send their weight reading, following which they received a supportive message. Text messages were administered by an NHS service. Text messages asked for the participant's weight and responded with one of three options: • Weight maintenance or weight loss from previous reported weight -congratulatory message and encouragement to keep up the good work; • Small gain for one or two weeks in succession -advice to be careful about diet and increase physical activity • Gain for three or more weeks in successionoffer of telephone support session • If the participant continued to regain weight they were offered referral to a health trainer.
Could the intervention group withdraw?
Participants could withdraw from receiving text messages by replying stop. Participants could withdraw from the trial at any time.

Statement of ethical approval
Ethical approval was obtained from South Birmingham Research Ethics Committee (12/WM/0372).

Data analysis
First, we adopted a qualitative content analysis approach to compare accounts on a similar range of topics by going through each transcript line by line. This was completed independently by MS and OA for three transcripts. Transcripts were descriptively coded by MS and OA, with a sample verified by another researcher (KJ) to increase methodological rigour [25]. Transcripts were coded with NVivo 10. We identified data of interest and ensured coding was complete prior to interpretation [26,27]. Second, we used axial coding to generate matrices based on similar phenomenon and making connections. We adopted a technique of writing and re-writing smaller themes which then led to integrative themes, which were based on descriptive codes being linked to existing literature.

Findings Attending commercial weight loss programmes
Men had a number of perceptions and consequent reservations before attending commercial weight loss programmes. These perceptions were based on an assumed level of universality across commercial providers based on wider societal views. For instance, concern with how they would be received by those already in attendance and becoming embedded within an existing group or being subject to gender discrimination: "I went to a (commercial slimming group) session but I didn't feel particularly that it was going to work for me. Whether it was just that individual group, I don't know but it didn't feel right for me...I went to another group and that actually had a male consultant PT5. " Predominantly, men felt that content delivered across commercial programmes was better suited to meet the perceived needs of women such as dieting and meal planning; however, men failed to describe how programmes could be better tailored: "It was more content, I think. It was the way they were describing the meal sizes and things like that. I don't think it was -it was more aimed towards the women losing weight in the way things were said as well PT8. " Paramount to attending commercial programmes was interactions with other group members and the nature of discussions that took place. Gender dictated the nature of the topics discussed with group members, where losing weight by dieting to improve physical appearance appeared to be of greater importance to female attendees. Moreover, some male participants initially felt singled out from the group: "I suppose there was a bit of embarrassment about being the male in a largely female dominated group PT5" Evidently, men wanted to attend weight management programmes with other men to create a sense of 'camaraderie': "The fact that I was one of only a couple of men [okay] I was, it's disheartening PT10" Clearly, men found it difficult to adapt to their minority status within group sessions. Nevertheless, many were able to build personal, friendly, and comfortable relationships with other members of the group (male and female) along with facilitators. The use of humour was used to mask the initial embarrassment of attending the programme [28]: "cos we used to have a laugh and a joke (smiling) PT2" For many, the continued support given by group members and facilitators provided motivation to continue with weight loss: "It's like you get an applaud from the group so that's the supporting part coming in for your weight loss and even if you've put weight on, you still turn up PT5"

Acceptability of the design and delivery of text messages
The text messages were designed to remind participants to self-weigh each week, so that they would be prompted to take action and modify their dietary and exercise behaviours to prevent weight regain. The intention was to reply to messages with ease and with minimal effort required to return a weight reading to the text messaging service: "Just a simple question 'What is your weight today?' Straight forward. And I sent back what it was [weight reading], PT1. " Sending a weekly request by text message gave participants greater control over when they chose to weigh themselves compared to group meetings. For men, the process of losing or managing their weight was a private dilemma; therefore, receiving text messages felt unobtrusive:  "I probably found it better as a text only because you can reply at your convenience whereas when they used to come through I used to be with friends or you know......it could have been an inconvenient time to take a personal call PT6. " Yet, many participants encountered technical problems using the text messaging service with reminders sometimes received before the initial request: "I didn't have much of a problem as such. It's just that texting was out of sync PT4. " The primary drawback was the lack of personalisation. Men expressed a preference for face-to-face communication or what was described a 'human' approach. Furthermore, text messages failed to encourage men to make behavioural changes which led many to withdraw: "If you hadn't lost any weight or up a pound or whatever they would say 'Oh, just keep trying and probably drink more water' and I did that for about two months probably and I was getting nowhere and I thought this is a waste of time. So I just stopped PT3. " As a result, the impersonal and detached nature of the text messaging service and the text messages left participants disenchanted with the service. Many made comparisons with commercial weight loss programmes, where they were receiving group support and weighed weekly with a facilitator.

Weight maintenance strategies
Throughout, men discussed a number of weight loss maintenance strategies devised from either attending commercial programmes or lay knowledge from family, friends, or the internet. Men described how they chose to accommodate deviant eating behaviour. For example, the following participant, in line with Slimming World content, described eating unhealthy foods as 'sins' , whereby sinful eating was permitted on a number a days a week: "I just be naughty and say well today I am just going to have an 'all sins day' and I just eat what I want as much as I want PT4. " Nevertheless, men demonstrated a greater knowledge of dietary control with regard to purchasing reduced fat food products, reading nutritional labels, and calorie counting: "I sort of study the labels when I buy things in supermarkets. I try and control my calorie intake on a daily basis PT7. " Technology and interactive sources were used, giving men access to a larger of pool of information that could be personalised to support weight management. Men were able to use social media applications and websites to support better lifestyle management through online groups/forums for moral encouragement: "I am on a close group on Facebook with members from [commercial slimming group] and if ever you are stuck for a recipe or...I mean I go on every night and see what other people are eating PT6. " Men varied in their frequency of self-weighing without reminders from the text message intervention; those who continued to attend commercial programmes self-weighed less and preferred to receive support from the facilitator, while others who regularly self-weighed could make changes to their diet readily: "I never used to weigh myself other than [commercial slimming group] because your scales can be totally different PT6. " "I used to weigh myself at least weekly [okay] in fact I used to put the weight in my diary so that way I could see if I was putting on weight and if anything that was the strategy I' d compare it week by week PT10. "

Environmental considerations
Men showed considerable awareness of the public health discourse surrounding obesity, weight loss and being encouraged to take up healthier lifestyles. Still, there was confusion over healthy eating messages and the nature of the environment men were living in. Most prominent were messages about food and drink: "One glass of wine is fine and another wine is better and one drink is okay, it's good for your heart or something, then it's no, no none of that, it's terrible mixed messages PT10. " Issues regarding personal control over lifestyle choices were discussed; notably, men recognised the need for external support to lose weight or change their lifestyle, although they needed to take initial steps to lose weight: "Sometimes the individual has to have a hard look at themselves and say 'Right, what are you going to do about it?' before the NHS starts to come on board PT5. " All participants recognised the importance of continued support from attending commercial weight management programmes. The weight loss experienced in the first 12-weeks of attending commercial programmes had encouraged men to continue after the free consultation period had ended: "I wanted to carry on, don't think at the moment I will be confident enough to stop going to [commercial slimming group], that I would be able to maintain weight loss so as far as I'm concerned, I will be going for quite some time PT6. " However, the primary barrier to continued attendance was the cost of commercial providers: "I mean it would be lovely if [commercial slimming group] is paid for by the NHS but I can't see that happening PT6. " Notably, participants supported the need for commercial providers to help with weight management, and other than the cost, found them well suited to address their needs of building confidence, continued motivation, and group provision.

Discussion
The objectives of this study were to explore older men's experiences of attending commercial weight loss programmes and understand their perceptions of weight management services, in particular text message support that encouraged regular self-weighing. We have contextualised our findings using the Romeo logic model developed by Robertson et al. [6]. Our findings are discussed in the context of this model. Analysis of interviews reveals men face a number of predicaments before, during and after attending commercial weight loss programmes.
Our sample demonstrated a distinct awareness of wider social and cultural discourses surrounding older men attending weight loss programmes. Men acknowledged they were entering a feminine space whereby their minority status could only be addressed with the presence of more men. This highlights the importance of the 'relationships' aspect of the programme, particularly the interaction between participants and programme deliverers. In contrast to existing published literature [9,12], many men in our sample reported discomfort attending mixed gender programmes i.e., feeling isolated, unable to relate with female attendees with regard to weight management, and desiring greater male camaraderie. These findings support the trend that men continue to be under represented in commercial weight loss programmes [6] and cite a preference for all-male groups [9,12] which can be effective [29]. Feelings of discomfort led to men choosing not to attend their allocated programme. However, the presence of humour encouraged men to build relationships with other members of the groups and facilitators [30]. Nevertheless, these views are specific to our older male sample, who may hold stronger objections to sharing health spaces with women. In comparison to a qualitative study exploring men's views on weight loss (mean age 37 years), older men in our sample were more likely to identify socio-environmental factors as barriers to successful weight management rather than a lack of knowledge [23,31].
The men in our sample acknowledged the importance of continued support to maintain weight loss. There appeared little or no issue with using the messaging service; registering, understanding requests, and replying to messages with a weight reading. Issues arose with the design and delivery of the service; in particular, participants received reminder text messages before the initial request for their weight, probably due to poor mobile signals. Consequently, the successfulness of encouraging participants to self-weigh was dependent upon mobile signal connectivity-ensuring the correct message was sent and received at the designated time. Yet, men showed a willingness to continue monitoring their weight-related behaviour, albeit continuing to attend weight loss providers to weigh themselves.
Our findings differ from existing literature, with men contextualising their own eating and lifestyle behaviour in light of wider cultural, social and political considerations about obesity as well as the level of personal choice they exercised. Conversely, there was recognition that 'choices' were the product of individual preferences combined with knowledge and provision from the NHS and/or commercial providers. Though, all recognised the need for continued weight management support.

Strengths and limitations
This is the first study to explore the views of men attending commercial weight loss programmes and using a text message based weight management service encouraging self-weighing. However, our sample was limited to 10 participants, comprised of older men and subject to significant non-response; therefore, views may differ for those who are younger. We were only able to recruit two interviewees from minority ethnic groups. We were unable to consider the psycho-social, personality or socio-environmental variations in depth due to a small sample; but, we were still able to reach theoretical saturation.

Policy recommendations
Commissioners of weight management services need to consider the specific needs of men, where male participants can share their experiences and feel part of the group rather than seen as minority that is difficult to cater for. This may be through encouraging commercial providers to adapt their programmes or by commissioning male only programmes. However, a review by Williams et al., investigating the effectiveness of weight loss interventions for men and women, found no evidence to suggest men and women should adopt different weight loss strategies [32]. Text message support has limited influence when encouraging men to self-weigh in comparison to receiving face-to-face provision from peers or facilitators. Men who attend weight loss programmes continue to perceive that weight loss strategies such as dieting remain a feminine preoccupation which may result in possible attrition. Content should focus more about healthy eating in the context of managing health related concerns [6] while weight loss interventions need to create an atmosphere that encourages camaraderie and humour; both could increase attendance [6]. The cost of attending commercial providers remains a barrier whereby financial subsistence could aid those from disadvantaged backgrounds.

Conclusion
In summary, overweight or obese men face potential conflicts when deciding to attend weight loss programmes and the nature of support they wish to receive post attendance. Men show little apprehension to attend weight loss programmes, however, feel that the presence of more men and altering content away from perceived female domains would help concerted efforts to lose weight. Evidently, men require continued support even after attending weight loss programmes. Men did not reject the idea of receiving text messages as a form of self-weighing support but prefer weekly group based provision. Hence, the nature of text support needs further consideration and re-design before it can be used for weight management.