The OBBs included 23 participants: 11 from the UK and 12 from the USA and aged between 35 and 65 years with a mean (BMI) of 35 (BMI range 30–39). Ten participants (five each from the USA and the UK) had experienced a previous CV event (group I) and 13 participants (seven from the USA and six from the UK) had other comorbidities or risk factors but had not experienced a prior CV event (group II). Table 2 details baseline characteristics of the participants.
Qualitative Insights Gained from the OBB
Thoughts About Obesity Triggered Negative Emotions
On day 1, the participants in both the groups expressed a generally positive attitude; as the study progressed, their “true inner feelings” became evident. Though it was observed that the number of participants expressing negative emotions was higher in group II versus group I (13 versus 8), it was inferred that the self-perception of the participants was negative on the whole (Table 3).
Physical and Emotional “Triggers” Resulted in Obesity
All the participants in both groups attributed their weight problem to various physical (e.g., giving birth or accidents that led to reduced mobility) and emotional (seeking comfort in food to overcome troubled relationships, problems at work, or with family) “triggers.” According to the participants these physical and emotional problems caused them to consume more food resulting in weight gain. During the daytime, participants indicated that they “put an act on” to show that all was well. The evenings and nighttime were the periods of maximum struggle, when the participants sought comfort in food to overcome their loneliness, boredom, and stress. A few quotes from participants associated with these findings are listed below:
“I seem to have a handle on my food consumption until nighttime. That is when I lose myself and my control.”
“I think that sometimes boredom kicks in and you crave something just to do.”
“I have trouble sleeping and get up at silly times of the night, and that’s when I begin looking in cupboards, fridge, etc. to find something to eat.”
Impact of Obesity on Daily Lives
Obesity had a psychological bearing and negative impact on the social, intimate, and work life of the all study participants irrespective of their CV risk (Table 4).
Anxiety and Apprehension
A total of 14 participants (5 in group I and 9 in group II) were anxious or apprehensive about their condition (Table 3). External appearance emerged as the primary cause of concern for almost all these participants, as opposed to the medical/health consequences of obesity. Participants from group I were relatively more up-front about having to encounter health issues such as heart problems, stroke, organ failure, T2D, and knee problems, though secondary to appearance. They also talked about reduced life expectancy and mobility, losing independence, and not being there for their children and grandchildren. Compared to group I, participants in group II did not discuss much about the health-related aspects of obesity unless prompted by the moderator to do so.
Measures Undertaken to Lose Weight
Although all participants in both the groups mentioned “diet” as a measure to lose weight, they refrained from mentioning the term “lifestyle changes” spontaneously. In their attempts to manage weight, all the participants in both the groups had tried/were trying different dietary regimens and weight-loss programs, which were often self-selected and not necessarily through medical referral, and often executed irregularly. Approximately 70% of the participants in both the groups sought help from healthcare professionals (HCPs), and almost all of them had tried medications (over the counter and/or prescribed) and also used digital health apps.
The reason to start on a diet or weight-loss program was almost always driven by a short-term goal and linked to a specific future event (e.g., holidays, weddings, Christmas festivities, or meeting someone and wanting to look their best).
The various motivators for the participants to start on a diet are summarized in Table 5. While four participants from group I mentioned health concerns as the primary reason for starting on a diet, none from group II mentioned the same. All group II participants stated that they went on a diet because of emotional/physical reasons.
Challenges Identified by Participants in Losing Weight
It was noted that almost 60% of the participants in both the groups set unrealistic and overambitious weight reduction goals for themselves (Table 6). The participants often tended to complain that their respective diet plans, physical activities, and/or weight-loss medications did not show quick results, resulting in frustration, loss of motivation, and discontinuation.
It was noted that participants were conscious about their appearance and felt embarrassed around other people. This prevented them from visiting the gym, or participating in open meetings or events conducted by organizations to manage weight; rather, they chose to sit at home, and in many cases indulged by finding emotional solace in food. Although a need for lifestyle modifications along with taking medications was understood by the participants, approximately 80% of participants in both the groups found it hard to execute and incorporate it permanently. The lack of adherence was mainly because of an absence of personal drive or motivation and due to the “fear of failing again,” based on their past experiences (Table 6). It was also observed that the participants lacked knowledge (or at least claimed to) on what healthy eating meant.
Those with a history of using weight-loss medications mentioned that they were not persistent with the medications because of the “side effects.” Interestingly, the medications were often blamed to be too short-acting and having a “plateau effect”—significant weight loss in the beginning after which they seemed to stop working and were discontinued. The participants blamed this as the reason for them to regain their lost weight.
The participants also felt that they did not receive enough support from HCPs, friends, or family members to achieve their weight reduction goals. The participants were not satisfied with HCP visits, which included general practitioners (GP), family doctor, dietitian, and/or nutritionist. Approximately 40% of participants in both groups I and II felt that GPs did not see the situation from their perspective and had limited time for them. They felt that HCPs were keen on advocating lifestyle modifications but were reluctant to prescribe weight-loss medications and the participants said that they had to often “proactively” request weight-loss medications. Participants in group I felt that their physicians were usually overly aggressive with their advice, as they were at a higher risk of developing further CV problems. It was also acknowledged that there was limited support from friends or family members to help them adhere to and successfully implement their weight management programs.
Trapped in a Cycle
From the interactions it was inferred that all participants felt “trapped” in a cycle of weight gain and weight loss, from which they thought they could never break free. The participants acknowledged that once they lost some amount of weight it was soon regained. This was primarily because of lack of long-term planning, and lack of guidance and support mechanisms. The weight gain further impacted their daily lives and they turned to the comfort of food more to overcome various physical, emotional, and social problems associated with being obese (Fig. 1).
Needs and Aspirations Regarding Future Treatments
As most of the participants in the study had already tried weight-loss medications in the past, with the feeling they were either “ineffective” or “too short-acting”, they aspired for “a magic pill” that could effectively manage their weight without much effort from their end. Ideally, they desire a drug that would allow them to continue with their old eating and lifestyle habits, whilst helping them achieve their weight goals. Participants also wanted the drug to not have too many “side effects.” The participants tended to categorize their goals into both short- and long-term. The short-term goals identified were noticeable weight loss (1–2 lb lost in a week) along with a reduction in abdominal fat, increased physical fitness, ability to wear nice clothes, and prevention of diabetes or high cholesterol levels. Long-term goals included losing a good amount of body weight by the end of the first year of treatment, without regaining the lost weight again.
Support Systems or Programs
When probed on the additional requirements that were essential to help participants achieve their weight reduction goals, 70% of participants in group I and nearly 40% of participants in group II desired for support systems or programs. Unlike the existing large online weight-loss support groups, which were felt to be targeted primarily at more athletic/fit and healthier individuals, participants expressed a desire for a small local online social group of “people like me,” where they could understand each other’s daily challenges and extend emotional support (similar to the OBB platform), along with a support app for helping them achieve targets. The participants also expressed the need for a moderator (e.g., a nutritionist or a nurse) for such online groups who could check-in regularly, answer questions, share tips, and track progress. The participants also valued having a 24-h toll-free support line as well as some form of encouragement such as e-mails, texts, or a reward program to achieve their weight reduction goals.