Overweight men's motivations and perceived barriers towards ... - Nature

European Journal of Clinical Nutrition (2007) 61, 526–531

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ORIGINAL ARTICLE

Overweight men’s motivations and perceived barriers towards weight loss MS Sabinsky1, U Toft2, A Raben3 and L Holm4 1 Suhr’s University College of Nutrition and Health, International Knowledge Centre, Copenhagen, Denmark; 2Research Centre of Prevention and Health, Glostrup University Hospital, Glostrup, Denmark; 3Novo Nordisk A/S, Clinical Research Dev Projects, Copenhagen, Denmark and 4Department of Human Nutrition, The Royal Veterinary and Agricultural University, Frederiksberg C, Denmark

Objective: To explore motivation and perceived barriers towards weight loss among Danish men. Design: The study was of an explorative nature, using qualitative focus group interviews as a method. Setting: Copenhagen, Denmark. Subjects: Twenty-two overweight men, at the age of 25–44 years and motivated for weight loss, were recruited and distributed into four focus groups. The men were primarily unskilled workers. Overall 13 men participated and each group contained three or four participants. Intervention: The interview guide was partly structured, partly unstructured and the themes of the interviews were motives and perceived barriers towards weight loss. Results: Main barriers for losing weight appeared to be lack of motivation and the perception of the slimming diet. The men had a desire to have a lean appearance and avoid illness, but in all the interviews it appeared that the strongest motive for losing weight was a strong desire to become more effective and a greater asset for one’s workplace. Overweight subjects were considered less effective and attractive for the labour market. Conclusion: This study indicates that if men from lower socioeconomic backgrounds are to be motivated to weight loss the focus should not be on leanness and good health but rather on increased effectiveness and performance, and the arena should include the working place. Sponsorship: The Royal Veterinary and Agricultural University supplied the necessary equipment and conference rooms.

European Journal of Clinical Nutrition (2007) 61, 526–531. doi:10.1038/sj.ejcn.1602537; published online 20 September 2006 Keywords: weight loss; focus group interviews; health; appearance; effectiveness

Introduction Weight gain and obesity are posing a growing threat to health in countries all over the world (World Health Organization (WHO), 2000; Bendixen et al., 2004). The Correspondence: U Toft, Research Centre of Prevention and Health, Glostrup University Hospital, Nordre Ringvej 57, Building 84/85, Glostrup DK-2600, Denmark. E-mail: [email protected] Guarantor: U Toft. Contributors: MSS and UT performed the focus group interviews, conducted the data analysis and were responsible for the interpretation of the data and drafting the manuscript. LH and AR helped design and were supervisors on the project. All the authors participated in editing the manuscript and provided advice regarding interpretation of the results. Received 5 December 2005; revised 19 June 2006; accepted 30 July 2006; published online 20 September 2006

National Institute of Public Health in Denmark has estimated that the prevalence of overweight Danish men is 50% compared with 34% of the Danish women (Kjøller and Rasmussen, 2002). Overweight and obese men are more likely than women to carry excess body fat around their waist and upper abdomen, which is associated with an increased risk of many health problems and men may benefit more from weight loss than women, because of the change in fat distribution following weight loss (Wirth and Steinmetz, 1998). Nevertheless, multiple studies have shown that men to a lesser extent than women try to lose weight, and significant fewer men than women participate in organized weight reduction programmes (French and Jeffery, 1994; Bendixen et al., 2002). Several reasons for this could be hypothesized: men are perhaps not motivated for weight loss, or they may

Preventing obesity in men MS Sabinsky et al

527 perceive too many barriers towards weight reduction. A third reason could be that current weight reduction programmes and public health campaigns do not appeal to men. These issues are important to investigate in order to help design a more targeted endeavour to prevent obesity among men. Studies clarifying the motivation of men toward a lean body and weight loss are very sparse. Egger and Mowbray (1993) conducted focus group interviews among working class Australian men. They found that the main reason for wanting to lose weight was to feel better, whereas health was never mentioned spontaneously as a motive for wanting to lose weight. Contrary, Hankey et al. (2002) found that the main reason for seeking weight loss among a group of British overweight and obese male workers was that this would be beneficial to health. Only the study of Egger and Mowbray (1993) reported perceived barriers towards weight loss: Men felt that they would have to eat less than usual, they had little interest in increasing their exercise load and they lacked time. A good weight reduction programme was described as one where a lot of weight was lost quickly. Thus, the results are contradictory and limited and there is therefore a need for much more research in this area. The present study explores motivations and perceived barriers to weight loss among men with lower educational background.

Methods The study was of an explorative nature, using qualitative focus group interviews as a method. Through open-ended questions and group-interactions, we were able to study the spontaneous expressions of ideas and norms about body weight and weight loss in groups of overweight men. Overweight (25–30 kg/m2, estimated using self-reported data on weight and height) men between the age of 25 and 44 years who expressed a wish to loose weight were recruited. Recruitment was made through (1) a personal invitation sent to individuals, who had earlier applied to participate in weight reduction programmes at the Department of Human Nutrition (2) snowballing among workers at a refuse disposal plant and porters at a hospital. Both working places were situated in Copenhagen, and initial contacts were made through leaders at the working places. Recruitment for focus group interviews can be difficult and snowballing optimizes the chance for getting men with lower socioeconomic status to participate (Krueger and Casey, 2000). Overall, 22 men were recruited and distributed to four focus groups. To ensure some degree of homogeneity within the groups, the groups were divided according to educational level (Bojle´n and Lunde, 1995). Two groups consisted solely of unskilled workers and two of men with 0–4 years vocational training. The interview guide was partly structured and partly unstructured. It included four themes, an introduction and an ending. The four themes were (1) motives for weight loss, (2) experiences with attempts to loose weight, (3) barriers to

obtain a weight loss and (4) the ideal weight control programme. The interview guide was designed to maximize the use of input from the participants. Data on the motives of the participants were assessed through a projective technique. The participants were asked to illustrate the lives of three fictitious overweight men, at the age of 25, 44 and 65 years, respectively, by drawing and simultaneously discussing what the participants imagine characterizes these men. Subsequently they were asked to illustrate the lives of the same men after a 15 kilo (33 pounds) weight loss. Motives for weight loss also appeared unprompted throughout the interviews in other sections discussing own experience with weight loss and ideal weight loss programmes. Data about experiences with loosing weight appeared in sections where each of the men talked about their own wishes for weight loss and if and why they had tried to lose weight. Data on barriers towards weight loss were assessed through a brainstorm among participants about the barriers they perceived to weight loss. The barriers were written on cards and combined with cards, which the researchers had made before the interview containing potential barriers. The later included both barriers associated with dietary changes and increased physical activity. The men were subsequently asked to sort the cards in three categories: relevant, potentially relevant and not relevant barriers. During the sorting process the men were asked to explain the rationale behind their sorting. Data on the wishes of the men for weight control programmes were assessed by another brainstorm about how to improve the chances of the men for weight loss. The brainstorm was followed by a task, where the men as a group designed an ideal weight loss programme. Again, the researchers had produced cards describing elements (including both physical activity and diet), which could be included in the programme, and these were combined with cards with ideas that the men came up with during the task. The interview guide was slightly revised after a pilot focus group test.

Data analysis The focus group interviews were audio- and videotaped. The videotapes were used for the data analysis. In the data analysis the tapes were transcribed verbatim, and the text was coded independently by two investigators. Categories for index coding were made before coding. The categories were: reasons for weight loss, cause of overweight, lifestyle of a lean person, dietary habits of a lean person, lifestyle of an overweight person, dietary habits of an overweight person, masculine ideal of the body, ways of losing weight, the participants own motives for weight loss, perceived barriers. The codes for the weight control programme were subdivided into the following categories: content of the programme, responsible institutions, profession of person in charge, organization, duration and communication. The codes served as basis for a thematic analysis in which main European Journal of Clinical Nutrition


528 themes in coded segments were identified and condensed (Kvale, 2000). During the coding process the data were checked for supplementary topics and deviant cases and it was ensured that all themes were included in the analysis. Afterwards the codes and condensations were discussed until consensus was reached.

Results Four focus group interviews were conducted in Copenhagen; nine persons failed to show up for the focus group sessions. Each focus group contained three or four participants. Table 1 shows some data of the composition on the groups. The number of participants in each group was smaller than considered ideal (Morgan, 1998; Halkier, 2002). However, the discussions in the groups were very lively and all participants took part in discussions with considerable openness and enthusiasm. In spite of educational differences between the groups the results from the interviews were very similar with respect to the motivation and barriers towards weight loss and also with respect to proposed weight loss programmes.

Motivation to loose weight All men who participated had previously tried to loose weight in different ways, without success. On several occasions during the interviews the men expressed a general wish for an easy way to lose weight. One man expressed it like this: Take a pill and wake up lean in the morning. That would be a good solution for most of us. I haven’t got any patience. If you can’t see it on the scales half an hour later, I give up [Electrician, group 1]. In the discussions of the drawings of the three fictitious men perceived motives for loosing weight and perceived advantages from weight loss appeared. The motives appeared to be changing with increasing age. Thus for younger men the main motive was perceived to be attractive and to get a girl friend, whereas well being and longer life expectancy was perceived to be main motives for older men. The view of the

overweight person changed with age too. A young overweight man was seen as an unfortunate fellow, whereas a middle-aged or old overweight man was seen as a cheerful man who had become overweight because he liked good food and wine. During the discussions of the drawings, and discussions of weight loss programmes for men, three main motives for men wanting to loose weight appeared: a desire to have lean and attractive appearance, an experience of a health hazard, and a desire to be effective and an asset for one’s workplace.

Appearance and health The desire to have a lean appearance showed to be rather ambiguous. The participants associated a lean body with a number of gains, including a beautiful, lean girlfriend, becoming popular and getting a better job. Nevertheless, it came out clear that these motives alone were not considered strong enough to motivate the participants themselves to try to lose weight. Unfortunate incidents or experiences were necessary in order for the men to take action. The participants described for instance how the young fictitious man had a desire to be lean and attractive but that he would not lose weight until his girlfriend broke up with him and he needed a new girlfriend. The men in the interviews stressed that health hazards of being overweight were more important than the desire to have a lean appearance and when the men were asked to describe the motives of the fictitious older men appearance was not mentioned. However, this could be an expression of a cultural norm that men are not supposed to be vain. In two of the interviews it was brought up that men do not talk about dieting. This is illustrated by the following quotation: y. it’s just a little too un-cool to have a need for slimming. That’s something women are talking about. Sometimes we are able to talk about it too, because everybody actually agree, but you can’t help making fun of it [Electrician, group 1]. Another reason why appearance seemed of little importance could be that the participants actually did not see themselves as particularly overweight. It appeared that

Table 1 Characteristics of the four focus groups

No. of participants* Age years, mean BMI kg/m2, mean Social status/education

Group 1**

Group 2**

6/3 39 27.6 0–3 years educ.

6/3 38 27.9 0–4 years educ.

Group 3 hospital porters

Group 4 Amagerforbrænding

5/4 34 29.8 Unskilled workers

5/3 45 29.4 Unskilled workers

*The number of men recruited for the group/the number of men who turned up and participated. **The men in group 1 and 2 were men who had earlier applied to participate in weight reduction programmes at the Department of Human Nutrition.

European Journal of Clinical Nutrition


529 participants found that an ideal male body weight would be at least 100 kg (220 pounds). The following quotations illustrate this: y..I may have too many kilos hanging around, but I don’t feel like a giant, and I would like to lose weight but I don’t go around and feel bad about it [Hospital porter, group 3]. Men are very uncritical y..when they look in the mirror they really think they look damn good [Electrician, group 1]. You can’t trust a man less than 100 kilos [Journalist, group 2]. Every thing less than 100 kilos is gay [Unskilled worker, group 1]. The experience of concrete health hazards seemed, however, to be an effective stimuli to serious attempts to lose weight. Thus, some of the participants explained how seeing the illness of a colleague or friend would motivate them to lose weight. Especially, the experience of a personal health threat appeared effective. Thus, some of the men described how their doctor had diagnosed high cholesterol levels or high blood pressure, and afterwards they had lost weight. However, after some time or when the cholesterol level was decreasing, their motivation dropped and they gained weight again.

Effectiveness and the working place The strongest motive for weight loss appeared to be the desire to be effective and valuable for the labour market. There was a clear tendency in all interviews that people, who were perceived to be overweight were considered less effective, were giving their company a bad image, and were individuals with a lot of sick-absence. Overweight people were described with words like ‘a poor life’. Thus, the participants suggested that employers should demand lean employees. It was considered that this would be a very strong stimulus for men to try to loose weight. This is illustrated in the following quotation: There should be some reprisals – no wage increase if you don’t loose 10 kilos (22 pounds)y.because you’re not attractive to the company. You are not productive enough and you have too much sickness absencey[laughing], hypothesising about a situation in the future] there is this private health insurance that many companies take out and the companies have to pay an extra 10 000 DKK for you because your BMI is over 30. TRYG [large Danish insurance company] have now decided that you are not a good prospect and the company can’t afford to employ you [Electrician, group 1]. Thus, the men focused on the profit of the companies and workers’ effectiveness in a rather straightforward manner.

Similarly, when the men were talking about their body or their health, some of them compared the body to a machine or a car that had to be checked and to be filled up with gas and oil in order to function well and be effective. Most of he participants did not appear to see it as problematic if employers would begin to demand lean employees. Only one man expressed an appeasing view: ywe are actually talking about making a whole group of people especially unattractive for the labour markety. [Hospital porter, group 3].

Barriers to loose weight Even though only men who had expressed a desire to lose weight were included in the study, the most frequently mentioned barrier for loosing weight was lack of motivation. This was also supported by the wish for an easy way to loose weight, as described above. Another important barrier appeared to be the participants’ perception of the kind of diet they thought they would have to eat if they wanted to loose weight. Compared to the food they usually ate this diet was thought to contain much more vegetables and little or no meat and alcohol. When participants talked about this type of diet they called it names like ‘snake-feed’, ‘bran fodder’ or ‘green fodder’. Eating such food would make the men deviate from the social norms and conventions among their friends and families. Additionally, the participants expressed that men are supposed to eat whatever is served and it is not acceptable for them to prefer a carrot for a piece of cake or a big piece of meat. Drinking beer or red wine appeared in the interview to be considered as fattening by the participants. Thus, the younger and the older men were illustrated drinking a lot of beer, and the middle-aged men drinking red wine. Furthermore, avoiding beer and red wine was repeatedly mentioned as an important barrier for weight loss. The participants also mentioned more practical barriers such as not having enough time for exercising or for cooking a different kind of food, the expected extra expenses in using for example fitness centres etc., and finally some men experienced it problematic to exercise instead of spending time with their family.

Weight control programmes In all interviews it was a repeated idea that effective weight loss programmes should take place at the men’s working places and in the social company of ones colleagues. Especially, the participants expressed a wish to exercise together with other men and especially male colleagues. It appeared to be important for the participants to join others they could identify with in weight loss programmes. At the same time many of the men expressed a wish for a very flexible and individually designed programme, which included personal counselling sessions as a supplement to European Journal of Clinical Nutrition


530 the activities taken place in the company with their colleagues. Some of the men also emphasized that competition among participants in the programme would encourage them. And instead of focussing on the weight loss, some of the men proposed to focus on a better performance of the body. When communicating to men about weight loss, the participants stressed the importance of humour and a positive tone. At the same time, however, they also mentioned the importance of all communication being serious and reliable.

Discussion The use of focus group interviews proved to be fruitful for the aim of this study. The interaction between the participants readily gave information about men’s universe when it comes to dieting. The men were more willing to talk about weight loss and leanness than expected, and group discussions were lively and enthusiastic. Recruiting men for focus group interviews was difficult, and several of those who had accepted our invitation never showed up. The participants were mostly men from lower socioeconomic backgrounds, but the few participating men from the middle class seemed to share the same point of views as the others. However, our data material is too small to make any systematic judgement about this. More systematic research about a possible difference between different social classes needs to be carried out. The men in this study wanted to lose weight, but they had not had any success with it. The main problem as they saw it was their lack of motivation or difficulties in keeping it up, partly because the men were ambiguous about whether their masculinity would be threatened. On the other hand, when called upon to reflect upon individuals, who were defined as overweight the men felt that weight loss was relevant. According to Prochaska and DiClemente’s Stages of Change model, motivation is an important factor for changing behaviour (Prochaska et al., 1992). If the men feel motivated the progression through the different stages towards a change of behaviour will be easier and the risk for relapse will be reduced. Further for behavioural change to be successful it is important to address perceived barriers. Our results indicate that an important barrier to the men was their partly misinformed perception of the kind of diet they would had to consume if they wanted to lose weight (Nordic Nutrition Recommendations, 2004). Compared to the diet they usually consumed, this diet appeared to the men to be almost ascetic: containing a very large amount of vegetables and little or no meat and alcohol. Other studies have shown that a diet rich in fruit and vegetable and poor in meat can be a barrier to men: several studies in Western cultures have shown that men in general prefer more meat than do women, while women prefer more fruits and vegetables (Andersson, 1980; Holm and Møhl, 2000). European Journal of Clinical Nutrition

Symbolically, meat eating is traditionally associated with attributes of power, aggressiveness, strength and masculinity. In contrast, vegetables are associated with femininity and lightness (Andersson, 1980; Holm and Møhl, 2000; Roos et al., 2001). Furthermore, alcohol appears to be an important symbol of masculinity. In many cultures, to drink and to become drunk reflects an attempt to behave in accordance with male gender expectations (Holm and Møhl, 2000; Roos et al., 2001). It follows that the participants’ perceptions of necessary dietary change implied a potential loss of masculinity. Consequently, the participants expressed that they saw dietary change as a barrier for weight loss. They expressed that as men they are expected to eat a lot and to eat what is served. This is in accordance with the literature which states that men are not supposed to be picky (Andersson, 1980; Holm and Møhl, 2000; Roos et al., 2001). Traditionally, good health and a leaner body are the motivational factors emphasized in public health campaigns and -information materials. The results of this study indicate, however, that men from lower socioeconomic backgrounds do not experience such factors as central to them, but rather as themes belonging to the female world. Thus, a wish for a generally good health was not a prominent theme for the men. This is supported by the findings of Cameron and Bernardes (1998), who describes that health is considered the responsibility of women. However, avoiding illness or death appeared to be essential and relevant to the men from lower socioeconomic backgrounds, especially with growing age. Thus, men focus on the health hazard of overweight but not on being generally healthy. Furthermore, it was expressed that slimming is not a theme for men to talk about. The men considered this as a women’s theme. Additionally, being a ‘small’ man was associated with weakness or homosexuality. This is in accordance with the results of earlier studies of both Connell (1995) and Ziebland et al. (2002), who report that underweight is less acceptable for a man and that the size of a man’s body is important for his perceived degree of masculinity. Thus, leanness and general health do not appear to be strong motivational factors for men to enter weight loss programmes or to work for weight loss in other ways. The men in this study talked about overweight and weight loss in a manner which was in contrast to the form weight loss is discussed in public health and weight loss programmes. Instead of relating overweight to appearance or to health, the men related overweight to the work place and to effectiveness. A personal desire to be effective and attractive to the working place seemed to be a very strong motivational factor towards weight loss. In line with this finding the men used metaphors relating to machines or cars when they illustrated matters about health or their bodies, and effectiveness was a key word when discussing obesity. That work and performance are important to men’s identity and masculinity in all social classes is also supported by the


531 literature (Carlsen, 1990; Connell, 1995; Moynihan, 1998; Roos et al., 2001) and men comparing their bodies with machines or cars is also seen in other studies, where it has been shown that men relate to the performance, and to input and output of their body instead of its inner feelings and senses (Cameron and Bernardes, 1998; Moynihan, 1998). In conclusion, this study indicates that there is a need to change communication about weight loss if men from lower socioeconomic backgrounds are to be motivated. Leanness and health are seen as feminine themes and when communicating with overweight men, focus should not only be on the amount of weight loss or the size of the body but rather on effectiveness and performance, such as the improved ability of running faster or longer, manage work better etc. It also appears that if men from lower socioeconomic backgrounds are to be motivated to weight loss the arena to which this theme should be linked must include the workplace. The present study was small and exploratory. Clearly more research need to be conducted in this area, but our study does suggest that the motivational factors that men from lower socioeconomic background find relevant differ from those of women. This should be considered, when planning efforts to prevent obesity and improve nutrition and health in men.

Acknowledgements We acknowledge The Royal Veterinary and Agricultural University for supporting this study by supplying the necessary equipment and conference rooms.

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