Background Overweight and obesity are considerable public health issues internationally as well as in Sweden. On a global level, the obesity prevalence has nearly doubled over the last 30 years. Currently in Sweden, more than one third of all women, and slightly more than half of all men, are either overweight or obese. The long-term results of obesity treatment programs are modest as reported by other studies. The importance of extending the focus to not only obesity treatment, but also prevention of weight gain, has therefore been emphasized. Aim The overall aim of this thesis is to explore the concept of primary weight maintenance (PWM) and to increase the knowledge of the attitudes, behaviours, strategies and surrounding circumstances that are important for PWM in a Swedish middle-aged population. Material and methods All study participants were recruited based on their previous participation in a health survey in their home setting; The Västerbotten Intervention Programme (VIP) in Västerbotten Sweden (paperI-IV), or the Upstate Health and Wellness Study in Upstate New York (IV), USA. All subjects had participated twice, with a time period of ten years between health surveys. The prevalence of obesity between the years 1990-2004 was calculated for VIP participants (paper I). Ten-year non-gain (lost weight or maintained body weight within 3% of baseline weight) or weightgain (≥3%) was calculated for individuals aged 30, 40, or 50 years at baseline. A multivariate logistic regression model was built to predict weight non-gain. In-depth interviews were conducted with 23 maintainers and four slight gainers in Sweden and analysed using Grounded Theory (paper II). A questionnaire study was conducted including 2138 Swedish and 2134 US participants (paper III and IV). Analysis of variance (ANOVA), correlation, and linear regression were performed to identify attitudes, strategies, and behaviours that are predictive of PWM in different age, sex and BMI subgroups in Sweden (paper III). Further, the pattern of ten-year weightchange (% and kg) in 1999-2009 was calculated for Swedish and US women within different subgroups (paper IV). ANOVA, correlation and chi-squaretests were conducted to contrast eating and exercise habits between the two countries that may explain the differences in weight change. Results The prevalence of obesity (BMI ≥30) in Västerbotten increased from 9.4% in 1990 to 17.5% in 2004 (I). Older age, being female, being overweight at baseline, later survey year, baseline diagnosis of diabetes, and lack of snuff use increased the chances of not gaining weight. Based on the in-depth interviews, describing attitudes, behaviours and strategies of importance for PWM, a model was constructed (II). Weight maintenance was characterized as “a tightrope walk” and four strategies of significance for PWM were described as “to rely on heritage”, “to find the joy”, “to find the routine” and “to be in control”. The questionnaire study aimed at identifying predictors of PWM in different age, sex and BMI groups (III). The pattern of significant predictors was widely disparate between different subgroups. Of 166 predictors tested, 152 (91.6%) were predictive of PWM in at least one subgroup. However, only 4.6% of these were significant in half of the subgroups or more. The mean percent weight changes (in all cases weightgain), between 1999-2009 for Swedish and US women, were 4.9% (SD=5.8) and 9.1% (SD=13.7) respectively (p for t-test˂0.001) (IV). For the US women, the largest weight change occurred among the 30 year olds for all three BMI strata. For the Swedish, it was seen among overweight and obese 30 year old women. The largest difference in ten-year weight change between the two countries for any two matched subgroups was seen in normal weight 30 year olds. Significantly more of the women in this Swedish subgroup stated having more of healthy behaviours. However, there was a tendency for unhealthy behaviours to be strongly associated with greater weight gain in the US, but much less so in Sweden. Conclusion: Younger individuals, those of normal body weight, and those without health conditions (e.g. diabetes type 2) and cardiovascular riskfactors – were the least likely to maintain their weight over the 10 year period (I). Educational efforts on the prevention of overweight and obesity should therefore be broadened to include those individuals. The in-depth interview study showed great variety with regard to attitudes, strategies and behaviours important for PWM (II). The results from this study informs health personnel about the need to tailor advice related to body weight, not only to different sub-groups of individuals trying to lose weight but also to subgroups of primary weight maintainers who are trying to maintain weight. This statement was also supported by the questionnaire data, where the large disparity in the pattern of significant variables between subgroups suggests that these interventions should be tailored to the person’s demographic (age,sex and BMI) (III). Paper IV showed that even though the prevalence of obesity among Swedish women has increased substantially during these ten years, it has not kept pace with the increase in the US. One explanation for this may be that normal 30 year old Swedish women have more healthy behaviours than do US women. However, the insensitivity of the Swedish women to weight gain for healthy versus unhealthy alternatives may also be a factor. If the exact reason behind this phenomenon can be identified this may contribute to a deeper understanding of PWM both in Sweden and the US.

A strategy for facilitating post-treatment weight maintenance was examined. Subjects were matched for age, sex, and amount of weight that they desired to lose and were then assigned to one of two groups. Both groups were under contracts and had individually designed self-control programs for weight loss, but subjects in the experimental group lost weight in small steps and subjects in the control group lost weight continuously. The experimental group was predicted to have better weight maintenance after treatment because of a greater number of reinforcements for weight loss. Two-month follow-up data was obtained on the ten subjects who completed the study, and the experimental group was found to have regained significantly less than the control group after treatment ended. The implications of these results for obesity research are discussed.

Övervikt och fetma beror till stor del på ändrade levnadsvanor och är ett problem att ta på största allvar eftersom fetma kan leda till allvarliga följdsjukdomar och sänkt livskvalitet. Preventiva åtgärder är nödvändiga för att hindra den fortsatta fetmaepidemin och här kan sjuksköterskan fylla en viktig funktion som stödjare och rådgivare för obesa personer. Syftet är att beskriva vuxna obesa personers upplevelser och hantering av viktnedgång. Metoden som använts är litteraturbaserade studier av åtta kvalitativa artiklar.De obesa personernas upplevelser framkommer i tre teman. Upplevelser innan viktnedgång beskriver olika stadier som obesa personer genomgår innan de beslutar sig för viktnedgång samt beskriver även upplevelser av fördömande attityder. Upplevelser och strategier under viktnedgång beskriver att livsstilsförändringar kräver ett stort engagemang och hur betydelsefullt det är med stöd både under viktminskningen men även lång tid efteråt. Upplevelser efter viktnedgång beskriver att lyckad viktminskning ger ökat välbefinnande och bättre funktionell kapacitet men att sedan kunna bibehålla vikten beskrivs som en ständig strid mot viktuppgång. Genom att ha kunskap om stadierna som de obesa upplever i samband med viktnedgång kan sjuksköterskan anpassa sitt bemötande utifrån aktuellt stadium. På så vis kan sjuksköterskan undvika att försöka motivera personer som inte är mottagliga för råd för att istället göra det vid tillfällen då det kan vara fruktbärande. Dessa kunskaper kan också öka den emotionella insikten om den obesa människans utsatthet. / Uppsatsnivå: C

This literature review was a selective examination of current obesity and physical activity research and opinions. Its purpose was more to evoke thought and discussion regarding the United States' obesity epidemic, rather than serve as an exhaustive account of prospective causes and solutions. Obesity and physical inactivity are major preventable health problems in the United States, but despite overwhelming evidence regarding the benefits of a healthy weight and regular physical activity, adult, childhood and adolescent obesity rates continue to escalate, creating significant health, medical and economic consequences. While obesity rates soar, a small population percentage has proven successful in long-term weight maintenance, even in the presence of significantly influential environmental and interpersonal factors. Reviewing strategies employed by National Weight Control Registry members, this literature review discusses the two behavioral components missing from standard or traditional, action-oriented intervention programs. Although th e Stages-of-Change Model ex plains an indi vidual"s readiness to change and the process in vo lved, se lf-effi cacy and self-regulating behav iors were shown to have a more positi ve effect on long-term maintenance. Thus, recommendati ons for practical appli cation include incorporating these behavioral components for a more effecti ve and client-centered interventi on program.

The purpose of the study was to examine what methods and strategies individuals use to maintain their weight loss. Another aim was to explore which factors can complicate or simplify weight loss maintenance. Fifty-four individuals who had maintained their weight loss more than a year, participated by answering a questionnaire. The questionnaire was constructed and distributed through the internet. The answers were registered in the program google docs.  The participants mentioned successful methods and strategies, such as exercising regularly, the majority exercised 30 minutes at least five times per week. Successful methods and strategies regarding diet for weight loss maintenance were to increase the intake of fruits, protein and vegetables and to reduce the intake of carbohydrates and sweets. To maintain the weight loss, social support was considered important, both during the weight loss period but also afterwards, while maintaining it. Other successful strategies were to weigh oneself every week and to exert control over the eating.  The conclusion of useful strategies for weight loss maintenance was according to the participants, to exercise regularly and to eat plenty of vegetables, fruits and protein and at the same time minimize the intake of sweets and carbohydrates. / Syftet med studien var att undersöka vilka metoder och strategier individer använder sig av för hållbar viktnedgång. Vad det är som kan göra att individer bibehåller sin viktnedgång och varför det kan vara svårt, undersöktes också. Femtiofyra personer deltog, varav 33 kvinnor och 21 män i olika åldrar. Kravet för att inkluderas i studien var att de skulle ha bibehållit sin viktnedgång minst ett år, då detta är definitionen på hållbar viktnedgång. Undersökningspersonerna deltog genom att besvara en webbaserad enkät med i huvudsak kvantitativa frågeställningar. En ökad konsumtion av grönsaker, frukt och protein och en minskad konsumtion av kolhydrater, sötsaker och snabbmat bidrog till hållbar viktnedgång. Regelbunden fysisk aktivitet var associerat med hållbar viktnedgång där vardagsmotion, promenader, styrketräning och löpning utgjorde den fysiska aktiviteten. Majoriteten av undersökningspersonerna utövade minst 30 minuters motion fem dagar eller fler i veckan. Att väga sig och ha kontroll över sitt ätande var ytterligare två strategier för hållbar viktnedgång. Socialt stöd under viktnedgången resulterade i att viktminskningsperioden gick snabbare för deltagarna samt att ju mer stöd som de hade, desto högre var sannolikheten att viktnedgången bibehölls. Konklusionen av denna studie är att för att en hållbar viktnedgång ska uppnås, krävs ett ökat intag av grönsaker, frukt och protein och ett minskat intag av kolhydrater och sötsaker. Regelbunden fysisk aktivitet tycks vara ett nödvändigt krav för hållbar viktnedgång, medan socialt stöd kan underlätta en bibehållen viktnedgång.

While traditional behavioral weight loss programs have been successful at producing weight loss, weight maintenance is difficult to achieve. Addressing stress, one major contributing factor in weight gain, may be a potential solution. The purpose of this study was to test a stress-management program (EBT) for changes in weight and blood pressure, and maintenance of those changes. Obese adults (N=33) were randomized to two weight loss groups for a seven-week intervention and a seven-week follow-up period: an intuitive eating group or a stress management group. The intuitive eating group did not have any statistically significant changes in weight or blood pressure at seven or 14 weeks. The stress management group had significant changes at seven weeks in weight (p=0.05) and systolic (p=0.005) and diastolic (p=0.05) blood pressure. Weight decreased by 2.9 pounds at seven weeks and decreased a total of 4.4 pounds over the 14 weeks (p=0.05) in the EBT group. The EBT approach appears promising for weight loss and weight maintenance. More research with larger samples sizes and longer trial periods need to be done in order to draw a conclusion on the usefulness of this intervention.

There is significant research evidence to demonstrate that physical activity can produce weight loss, weight maintenance and positive health effects in the overweight and obese. However, it can be difficult to get this population sufficiently active to achieve these benefits. This thesis reports on a series of studies that explore physical activity used alone and in conjunction with other weight management strategies. The primary aim was to gain a greater understanding about how weight loss and continued long term weight maintenance could be achieved. The first study was a systematic review on the dose of physical activity associated with weight loss and weight maintenance, it investigated if the current treatment dose was appropriate. The findings correlated with the recently published new CDC guidelines. In the second study, semi-structured interviews were employed to explore the attitudes and experiences of overweight and obese individuals towards weight loss and health. It was reported by participants that they prefer autonomy and personalisation to tailor weight loss and health strategies to their own lifestyles. It was also found that their knowledge base was confused and outdated. In the final study, a sample of overweight and obese adults took part in participatory action research with the aim to design and assess their own weight management programme. A multi-strategy weight management programme emerged that could be tailored to individual lifestyle. Tips and ideas were also devised to aid weight maintenance. This thesis found that the overweight and obese appeared to favour a multi-strategy weight management intervention that could be incorporated, personalised and tailored to their everyday lives. Physical activity (that was enjoyable, lifestyle or accomplished through accumulated bouts), dietary changes, education/improved knowledge base, support and weight monitoring all appeared to be important factors to aid weight management.

One-third of the American population is obese (1), and of those successful at losing weight, most return to their baseline weight within three to five years (2). In an effort to increase the success of weight loss maintenance (WTLM), research has focused on strategies that promote self-regulation (3). Self-regulation strategies, such as daily self-monitoring of body weight (4), increased step count (5, 6), and increased fruit and vegetable intake (7) have proven to be effective in long-term WTLM interventions. To date, increased water consumption has not been researched as a WTLM strategy, yet it has been shown to decrease meal energy intake (8, 9) and increase weight loss among middle-aged and older adults (10). The purpose of our first investigation was to determine if self-monitoring of increased water consumption facilitates WTLM over 12 months among middle-aged to older adults, when combined with other self-regulation strategies. Our second investigation was a review of WTLM literature to determine the translation potential published interventions using the RE-AIM (Reach, Efficacy/effectiveness, Adoption, Implementation, Maintenance) framework (11) to provide recommendations for future research. Our first main finding was that weekly tracking of these self-regulatory behaviors (self-weighing, step counts, fruit/vegetable intake) for 12 months promotes effective long-term WTLM among middle-aged and older adults. However, daily self-monitoring of increased water consumption (48 fl oz/day) did not appear to provide an additional benefit. Secondly, we have identified significant gaps in the WTLM literature that may hinder the translatability of existing effective interventions. Specifically, current WTLM research is limited in reporting important external validity factors (e.g. costs, adoption, participation rate). Available WTLM literature provided a more detailed overview of Reach, Efficacy, and Implementation, yet was little information on potential adoption, costs, or sustainability. Future work in this area should address these factors to increase the translation potential of WTLM interventions in clinical or community settings. / Ph. D.

Psychosocial differences between weight loss maintainers and weight loss non-maintainers were compared at least one year after reaching a medically approved weight goal through a medically supervised weight loss program. Research questions addressed differences between groups on the dimensions of somatization, obsessive/compulsive issues, interpersonal sensitivity, depression, anxiety, hostility, ability to resolve past emotional issues, social interpersonal relationships, and tolerance of ambiguity. The all-female sample consisted of maintainers of weight loss (N=30), non-maintainers (N=33), psychotherapy maintainers (N=14), and psychotherapy non-maintainers (N=ll). Research instruments administered were the Symptom Checklist-90-Revised, Fundamental Interpersonal Relations Orientation-Behavior, Personal Orientation Inventory, and Budner Scale for Tolerance/Intolerance of Ambiguity. To determine differences between groups, a t test was performed on data relating to the maintaining and non-maintaining groups. An analysis of variance was performed on data related to the maintaining, non-maintaining, psychotherapy maintaining, and psychotherapy non-maintaining groups. An intercorrelation matrix was completed for all variables. Non-maintainers of weight loss had significantly more difficulty with somatic problems as indicated in the results of both the t test and the analysis of variance (p < .009, p < .02, respectively). Non-maintainers expressed more complaints which focused on cardio-vascular, gastrointestinal, respiratory, and somatic equivalents of anxiety (headaches, pain, discomfort of the gross musculature). An analysis of variance showed non-maintainers (p < .05) to be significantly less effective in resolving past emotional issues than maintainers, psychotherapy maintainers, and psychotherapy non-maintainers. Non-maintainers were more burdened by guilt, regrets, and resentments from the past. Results of the analysis of variance indicated that psychotherapy maintainers (p < .03) were more socially adjusted than maintainers, non-maintainers, and psychotherapy non-maintainers. Inclusion and control subscales characterized psychotherapy maintainers to be more socially adaptable and flexible. They assumed responsibility without support of others and were less burdened with fears of helplessness and incompetence.

Medical and economic costs for obesity are estimated at $147 billion per year, yet less than 1/3 of overweight individuals successfully maintain weight loss. The literature is replete with descriptions of the problem and research on treatments, yet demonstrations of effective loss and maintenance are lacking. Missing is an understanding of the experiences of individuals who successfully maintained healthy weight loss, which could provide insights regarding effective psycho-social interventions. The purpose of this qualitative narrative study was to explore key events and experiences in the lives of former weight cyclers. The primary phenomena of interest included weight cycling and sustained weight loss. Self-determination theory (SDT) and social cognitive theory (SCT) provided the theoretical frameworks to explore concepts like autonomy, mastery, and vicarious learning, which are known to be associated with recovery from other addictions (e.g., smoking cessation, weight loss). Using the tradition of narrative analysis, the stories of 6 formerly obese weight cyclers revealed 5 major themes: structure, strategies, relationship/support, autonomy, and identity as a fat person. Findings support SDT and SCT as meaningful frameworks for understanding how severely obese individuals can attain successful weight maintenance. Findings from this study revealed elements not fully addressed by these theories, such as resilience, the diverse orientations to the problem, and overarching themes common to all participants. Findings can be used to place greater emphasis on psychological components such as autonomy, mastery, and relatedness, which are necessary for successful remission. Findings may contribute to reducing direct and related costs of obesity and improving quality of life for individuals and their families.