Living the dream – but not without hardship: stories about self-directed weight transformation from severe obesity

Abstract

The objective of this narrative study was to explore experiences and assigned meanings in stories about self-directed weight loss (WL) maintenance after severe obesity (SO).

Design

In-depth interviews were conducted with eight women and two men, aged 27 to 59 years, who had carried out self-directed WL from SO for 5 years or more.

Two themes ran across the stories

fear of weight-regain, and food and emotion. We performed a case-based narrative analysis of especially rich interviews that illustrate these. Results pointed to persistently cultivating new competencies, establishing new eating habits, re-establishing old physical-training habits, and forming new relational bonds. Participants reinvented themselves and their lives. However, the stories are not all about transformation, but also about new and old health problems.

Conclusion

The study directs attention to ‘different obesities’, not only to initial weight from which WL takes place, but also linked to the experiential horizons that the persons embody from childhood on. Furthermore, there was no way back in the present stories, always haunted in the wake of the lost weight. A double burden imposed on the person with obesity related to meta-stories in society deepens the understanding of this imperative: being vulnerable health-wise and exposed to stigmatization.

Keywords:

• Severe obesity
• weight loss maintenance
• self-directed
• narrative approach

Introduction

Weight loss after obesity¹ may be possible but, keeping the weight off is a challenge indeed. Understanding the phenomenon of weight-loss maintenance, and especially, after severe obesity, calls for a diversity of perspectives.

In western countries, weight-loss products and services flourish in the private sector, and in some countries, such as Norway, where this study is situated, health authorities offer weight-loss treatment at no cost to people living with severe obesity. Yet, attempts at weight loss exclusively by changes in lifestyle appear to be unsustainable in the long run for most individuals (Wadden & Foster, 2000)². About 20% of those who lose weight keep the weight off for ≥1 year (Dombrowski et al., 2014; Thomas et al., 2014; Wing & Phelan, 2005). Permanent adherence to a healthy diet and physical activity regimen is imperative to maintain the weight loss, not to mention overcoming physiological, psychological, and social factors that contribute to weight regain (Stubbs et al., 2011). As such, weight-loss maintenance can be characterized as a demanding, lifelong task (Greaves et al., 2017), and the risk of being labelled a ‘failure’ by society or by oneself if not accomplishing it, is imminent. The authors of this article intended to study this phenomenon from the perspective of weight-loss maintainers.

From the literature and previous work in the field, we know that qualitative health research on weight is sensitive, in that it might be considered normative. Consequently, we set out to establish our perspective with transparence for the reader from the outset. Our point of departure is not that people living with obesity should lose weight to live fulfilling lives. Our research approach is motivated by the knowledge that many people living with high weight bodies want to lose weight and live in a lighter body. Experience-based knowledge about how to accomplish this demanding goal is valuable to these people and those who aim to support their efforts. This study concerns stories about self-directed weight loss after severe obesity and keeping the weight off for the long-term.

Weight-loss maintenance strategies and processes have been described from various perspectives. In a phenomenological study, Collins investigated self-guided strategies for weight reduction and maintenance from the perspective of women with former severe obesity (Collins, 2011). The core themes from an analysis of in-depth interviews were: Adult onset of weight gain, Decision, Strategy, and Self-discovery. The author concluded that not being obese in childhood and/or adolescence contributed to the women’s strong desire and decision to lose weight in order to reinstate a former physical condition and self-image that they perceived as healthy. Self-guided strategies included raising awareness about caloric intake and eating habits, permanent changes in diet, and the establishment of routines to engage in physical activity well adapted to one’s situation and preferences. The women described self-discovery and self-rewarding processes related to feeling fit, increased energy, self-confidence, and recognition from others. In a systematic review of qualitative research on self-directed weight loss and maintenance, the authors investigated self-monitoring strategies (Hartmann-Boyce et al., 2019). The results indicated that self-monitoring, self-perception, and emotions were interrelated, and an increase in weight-related self-knowledge followed. Self-monitoring could be helpful, but it could also increase the risk for inducing shame and quitting a weight-maintenance project altogether.

In another systematic review of qualitative studies, the concept of reframing with regard to self-guided weight loss and maintenance was investigated (Hartmann-Boyce et al., 2018). Reframing refers to changing one’s way of thinking about weight loss and how to maintain it, in order to make it more achievable, durable, and less challenging. The results indicated that persons who internalized weight loss and maintenance as a way of living, instead of perceiving it as ever-lasting dieting, expressed fewer negative emotions and sustained their efforts. Research has also identified a range of factors associated with successful weight loss, such as reaching a self-determined weight goal early, regular physical activity, eating regular meals, reducing energy intake, increasing dietary fiber, vegetable consumption, self-monitoring, internal motivation, coping strategies to handle daily stressors, self-efficacy, psychological stability, and professional support (Coughlin et al., 2013; Elfhag & Rössner, 2005; Hartmann-Boyce et al., 2017; Ramage et al., 2014; Stubbs et al., 2011). Although research has provided indicators of long-term weight-loss maintenance and useful theoretical concepts, how some individuals maintain the weight loss while others do not, is not fully understood.

The phenomenon of obesity is interwoven in meta-stories of the culture. The dominant medical meta-story is about obesity as a disease, and a risk factor for a number of diseases. Obesity is medically defined today as a chronic disease, with a complexity of contributing factors: genetic, physiological, psychological, and social in character (Stubbs et al., 2011). Obesity, especially severe obesity, is statistically associated with the risk for a wide range of chronic diseases and health problems, such as cardiovascular diseases, type 2 diabetes, sleep apnea, gastro-esophageal reflux, some cancers, musculoskeletal disorders, psychological burdens, and disability, resulting in suffering and worry for the individual and healthcare costs for society (Berrington de Gonzalez et al., 2010; National Institute of Health, 2012; Parr et al., 2010; Prospective Studies Collaboration, 2009; The Emergency Risk Factor Collaboration, 2011; The Global Burden of Metabolic Risk Factors for Chronic Disease and Stroke, 2014; Viester et al., 2013). The authors of this article do not question the statistically reported associations between severe obesity and specific diseases and health problems shown in epidemiological studies, but we are concerned about a one-sided understanding of obesity as a sign of bad health.

Obesity is also a topic in a meta-story about social stigma. In an individualistic culture, where ideals concerning physical appearance, self-promotion, and self-creation are prominent (Lupton, 1995), as in western countries, such as Norway, obesity is indeed associated with stigmatization (Lupton, 2012). A review on the stigma of obesity (Puhl & Heuer, 2009) showed that obese individuals are highly stigmatized, which affects employment, health care, and education, as well as interpersonal relationships and the media, leaving people living with obesity vulnerable to negative stereotypes and social injustice. Furthermore, in a systematic review on weight bias internalization a strong, negative relationship between self-stigmatization among persons with obesity and mental health outcomes was shown (Pearl & Puhl, 2018). In another review by Puhl et al. (2020) evidence of weight stigma as a contributor to maladaptive eating behaviors and stress was deemed strong. Findings in these reviews call for prevention of and interventions to heal internalized weight-related stigma (Puhl et al., 2020; Salas et al., 2019).

In fat-studies, the terms used in the medical field are criticized for being part of a hegemonic story about medicalization and stigmatization of higher weight bodies in a society where fat-phobia exists (Meadows & Danielsdottir, 2016). To contest anti-fat discourses in the media, in the field of medicine and from health authorities, fat studies researchers use discursive strategies (see for instance Durocher, 2021). To counter processes of othering, using person-first language, such as persons living with obesity³, and avoiding the term obesity altogether are suggested in favor of terms like high weight bodies and body diversity (Meadows & Danielsdottir, 2016). Countering stigma and celebrating body diversity is at the heart of fat studies researchers’ standpoint, counter stories that the authors of this article welcome as necessary and helpful within the obesity discourse. At the same time, we want to recognize individuals’ experiences of health problems related to the materiality of high weight bodies. Warin (2015) warned against understanding health-related obesity science emphasizing the changing material/biological body as illness/health risk and constructionist approaches opposing fat-phobia and stigmatization in society as mutually exclusive. Rather, she asked for the interplay between them, and this ethos also guides the current study.

People living with high weight bodies suffer from a double burden; being vulnerable health-wise, and devalued by dominating cultural norms, which may induce self-blame. Losing weight from high weight bodies and maintaining lost weight is deemed imperative. The individual encounters an interplay between health concerns, and self-responsibility, and the pressure to adhere to the desired norms of the culture. Hence, the aim of this study was to explore stories about weight loss after living with severe obesity and maintaining the weight loss for the long-term by highlighting the perspective of the storyteller and interpreting the stories in the context of meta-stories about obesity in our society.

Methodology and method

In this study, we followed a narrative approach. Building on Riceour’s thinking (1991), our starting point was that stories about important aspects of people’s lives are anchored in their lived experiences, but actively formed by the storyteller. As such, stories are not a mirror of actual happenings and experiences of the past; they are about creating a coherent portrayal of what is happening in the storyteller’s life, and who the storyteller is aiming to become. As such, storytelling is a meaning making process, and provides the person’s life with some degree of unity and purpose (McAdams & McLean, 2013). As Riceour (1991, p. 21) claims, events and happenings are more than what just happens; they are what contributes to the progress of the narrative. Heterogeneous components are actively organized as a single story. Furthermore, the structuring of happenings and experiences within a time frame (past, present, and future) is a core element in storytelling. Events and experiences are structured as consequential sequences or plotlines (Riessmann, 2008) embedded in the context of which the storyteller is part. As such, the story’s what, how, and why are influenced by cultural norms and values, which are negotiated in the telling of the story to a specific who (interviewer, audience, or reader). Meta-stories in the culture, concrete situations, and personal history influence specific stories (Frank, 2010). In our context, the meta-stories at play in the culture are, as already mentioned, about the social stigma of severe obesity and the assignment of obesity as a sign of bad health. We will return to the possible relationships between a single story about weight loss and maintenance and the meta-stories at play in the Discussion.

The chosen data source was in-depth interviews, which are considered especially relevant when exploring stories about lived experiences (Kvale & Brinkman, 2008). With the use of broad open-ended questions, this type of interview offers opportunities for participants to tell their stories in their own words and own way of communicating; it also deepens aspects of the story by focusing on specific events, happenings, or experiences to illustrate them.

Recruitment and participants

Purposive sampling was used to recruit participants (Malterud, 2001). In order to include participants with experiences of self-directed weight loss after severe obesity, the following criteria were met: persons previously categorized as severely obese based on their body mass index (BMI)¹; persons who initiated the weight-loss process at least 5 years prior to the study; and those who had lost at least 10% of their initial weight and maintained at least 10% of the loss. Individuals who had undergone bariatric surgery were not invited to participate⁴. Participants were recruited with the help of general practitioners and representatives from established weight-loss programs. Ten persons of Norwegian ethnicity⁵ agreed to participate (Table 1).

Table 1. Demographic and clinical characteristics of the participants.

Characteristics	Count
Gender
Male	2
Female	8
Age
25–30	3
30–40	4
40–50	2
50–60	1
Cohabiting status
Married/cohabiting	8
Living alone	2
Education level
Maximum of 9 school years	1
High school, vocational training	2
University degree (minimum Bachelor)	7
Employment status
Full-time employed	7
Student	1
Sick leave or retraining	2
Highest BMI
35–40	1
40–50	7
50–60	1
> 60	1
Current BMI
20–25	1
25–30	5
30–35	1
35–40	3

Conducting the interviews

All of the authors served as interviewers; first-author in two, second author in three, and last-author in six interviews. One interview was a follow-up. The interviews were audiotaped and transcribed verbatim. On average, the interviews lasted 92 minutes, ranging from 59 to 125 minutes. Interviewers emphasized the importance of a quiet place and a time frame of about 2 hours, to ensure an open dialogue about participants’ weight-loss journey was possible. At the choice of the participants, interviews took place in their homes, or in a meeting room near the home, or the workplace of the participants.

Interviews started with time set aside for small talk and serving coffee/tea, after which the interviewer repeated the purpose of the study and stressed the researcher’s interest in investigating how participants lived through weight loss and maintenance for years after living with severe obesity. Broad open-ended questions were asked about six topics: I) Personal weight-loss journey⁶; II) Own body; III) Habits and practices to maintain current weight; IV) Social life; V) Health and a good life; and VI) Thoughts about the future.

Analysis

A narrative analysis is not one single method, but ‘a family of methods for interpreting texts that have in common a storied form’ (Riessmann, 2008, p. 11). In our case, we performed a thematic analysis inspired by Riessmann (2008), in which the particular story (the single interview) was the prime unit. Accordingly, we performed a ‘case-based’ analysis, making it possible to include extended accounts and interpretations of the single stories.

The researchers read each story separately, recording first impressions and themes. The team met to discuss in-depth what the single story conveyed. Then, each researcher read the material from the entire interviews, discussed themes running across the interviews that illustrated what seemed at stake in the stories, and illustrated variation. We agreed upon two central themes: fear of weight regain, and food and emotion. Fear of weight regain and of losing hard fought ways of living today, ran deep in the stories. Preoccupation with habits and practices to avoid regaining the weight dominated, but stories about being more flexible and adjusting one’s energy and habits were also present. As such, trusting that established habits would suffice to keep the weight off and fearing regain coexisted. Food and emotions were also very much present in some of the stories and identified as drivers of severe obesity in the first place. In other stories, food and emotions were lingering in the background. We chose three stories for further analyses, stories that were rich in their illustrations of these themes, including capturing significant variation. They also counter stereotype linking of severe obesity to social withdrawal/exclusion from childhood on.

The team agreed upon these analytic questions for further analyses of the chosen stories: What is at stake in each particular story? Which road forward to considerable weight loss does this woman/man talk about? What are the turning points in the story? What experiences, habits, practices, and coherent story lines that contribute to lasting weight loss are present in the story? Are there threats to lasting weight loss in the story? How does the future look in the words of the storyteller? The questions were applied by the first author to write a draft of the stories, which were discussed with and commented on by the co-authors.

During the analysis, we were inspired by Mattingly’s narrative phenomenology, where looking for and listening to the unfolding and enacted story’s drama is a core element. We inquired about how particular events, episodes, and situations stand out as meaningful in structuring the lived experience in consequential sequences aiming at a hoped-for future (Mattingly, 2010). This reading was especially helpful in more ways: capturing main themes across interviews, giving a ‘name’ to the three particular stories, and finding events and happenings at the core of significant consequential sequences in each story. A phenomenological analysis resulting in a meaning structure based on invariant meanings across all the interview material is published elsewhere (Natvik et al., 2018).

Researchers’ roles and reflexivity

The authors were senior researchers (2 physiotherapists and 1 psychologist), with research experience in the field of life after weight-loss surgery, knowledgeable about the difficulties found in research studies on lasting weight loss after severe obesity, and the health-related consequences and stigma associated with severe obesity. None had experienced being severely obese themselves. Being aware of and reflect on own position was part of the whole process. An attitude of respect, and recognition for what the participants had achieved was the starting point, and a wondering attitude about how weight loss and maintenance processes came about, were explained, and understood by the storytellers, themselves.

Ethics

Information about the study’s background, aim, and participation requirements was provided to participants in writing, underscoring voluntary participation and anonymity. Participants gave their written consent. The Committee of Ethics in Medicine approved the study (2012/1706/REK vest). We have taken steps to anonymize each of the presented stories, to ensure it is impossible for others than the storytellers themselves to recognize the humans in the story.

Results. Living the dream, but not without hardship: three stories

The stories of ‘Emily’, ‘Amelia’, and ‘Paul’⁷ illustrate the two central themes in the interview material, and variations related to them.

Living and sharing huge achievements, but haunted by the fear of weight regain – ‘Emily’

Emily is a single, well-educated woman in her thirties, who works fulltime and spends her spare time engaged in physical training. She lost 50 kilograms during the weight-loss process she began six years ago, and her weight has been stable. Emily’s story revolves around great achievements, boosting her self-esteem and feelings of being strong, fit, and invincible, but it also reveals feelings of being haunted by a fear of weight regain.

‘All or nothing’: a strong desire and decision to lose weight

Emily said that she has been ‘big’ since childhood. Her self-esteem was good, and she felt included among her peers; however, their acceptance of her was mainly because she was a skilled ballplayer. Being overweight began to bother her as a young adult. She did not quite remember what led up to her strong desire to lose weight for the long-term. Nevertheless, she underscored the ‘all or nothing’ character of her decision to lose weight and named it ‘the last effort’. Previous efforts had ended in weight regain. This time, she did not want family, workmates, or friends to know about her decision in order to avoid the pressure of expected success or failure, reminding others that, ‘It was my⁸ decision’.

However, Emily was aware that she needed some help to embark on this life-changing project. The coach in the weight-reduction program, which she attended, helped her establish a regular physical training regimen and change her food and eating habits. To succeed was paramount. Jeopardizing the project was out of the question. She ended friendships, which she considered to be hindrances to her weight-loss project in the project’s early phase. The new journey had its costs.

‘I Lived in a super-project’: a self-rewarding process’

When Emily began her weight-loss journey, her physical condition was poor, indeed: ‘I had big problems with walking on the treadmill for just five minutes – shortness of breath from the slightest physical exertion’. She started to set regular goals: first, the goal of being able to run, then, the goal of running one, then five kilometers, and so on. She developed strict routines for what, when, and how much to eat. Emily even kept a calories diary to control her food intake, and her weight loss simply took off. Every week she measured the amount of weight lost, and felt she was coping in a way she had never coped before. She explained this as a self-rewarding process based on: ‘… the number on the weight scale, and all the time increasing the training’. She and her training mate made mutual pacts and pushed each other towards new training goals. Her weight-loss story was suddenly a symbol of success for others after going public with it, which boosted her self-esteem, but also felt like an obligation. She described this phase as: ‘Existing in a successful super-project where everything was high. I lived almost on a cloud’.

In the aftermath, Emily questioned whether her practices and speed of weight loss that first year were health promoting only. To reach the next goal was overshadowing the need for dwelling on what was happening to her: ‘The readjustment in the body is huge, and even more so is the readjustment of the head … not thinking that I am the biggest person in this setting, and actually being proud of my body’.

Life now: enormous satisfaction, enormous hardship

Emily’s story about how her life has turned out seems to be a story of deep ambivalence. ‘My life now is work and physical training, that’s it’, she said. Being part of a sports milieu with shared ambitions further strengthens her iron will. The self-reward for stretching limits, reaching new goals, and supporting others is just where and who she wants to be. ‘Now, I’m living the life I want to live …, working hard, training hard, and competing (in sports) ‘. Great achievements that boosted her self-confidence have also made her trust her professional competence more fully, seeking further education and setting new goals in her work life.

Currently, strict control of her food choices and eating require more and more of Emily’s energy. She talks about being very strict about what she eats, weighing every single bit of consumed food and striving for the optimal composition of nutrients. This has been an essential part of the weight-loss process. However, strict control and fear of weight regain has turned against her. She recognizes having ‘a very difficult relationship with food and eating’. She actively involved a professional helper, and they collaborate around choosing goals to set. When asked about what is the most important to work on now, she negotiates with herself:

I sort of know that I do have control, like steel, over everything I do, I do not need to weigh that breakfast every bloody day. I know that it will work out well … but suddenly, the days come …., when eating something out of the ordinary, then the uncertainty is back.

Hoping to go on living this rewarding life, but without the fear of weight regain

When asked about future prospects, Emily emphasized her wish to go on with life as it is now: stretching her limits and continuing with great sport achievements. However, a strong desire is: ‘To be more relaxed about food and training. … Daring to see that it works well when eating a chocolate’. She longs for the ease of letting go of control without returning to her fear of weight regain and works for it to happen.

Living the life always hoped for, but being aware of threats of weight regain – ‘Amelia’

Amelia is in her twenties, has a small child, and is co-habiting with the child’s father. She is well educated and works fulltime. She started her weight-loss journey five years ago; she lost 55 kilograms and her weight has stabilized. Amelia’s weight-loss story moved from hardship and low life expectations to her deepest dreams coming true. She is aware of threats to weight loss; nevertheless, she trusts her present habits and practices to maintain her weight loss and counter the threats.

From no problem being a bit big, to a precarious situation as severely obese

Amelia talks about being ‘bigger than average’ from childhood onward. However, she did not experience being a bit big as a problem. ‘I have always loved being physically active’, she explained. Being a skilled ball player at a high level in her teens contributed not only to feeling she was in good shape, but also to her inclusion among peers and self-esteem. Severe overweight first appeared in the years when she was both working and studying. ‘It grew more and more problematic, health-wise’. Too much food and unhealthy food choices, irregular meals, and the habit of uncontrolled eating in the evenings are the explanations in her story. At home, healthy food was the rule. She alone is to blame for the road to severe obesity, she explained.

A turning point in her weight journey was an incident that made her realize how poor her physical stamina was. She and some friends were about to watch a ballgame and had to hurry. She was simply unable to keep up with their pace as they climbed a steep hill. Completely set back by this ‘eye-opening’ episode, this was a dark moment in her life: ‘I simply cannot live like this, I must do something’. She adds: ‘I felt so guilty’. She concludes: ‘My self-confidence was very low at that moment’. During this phase, having a boyfriend and establishing a family of her own, seemed unachievable. Her being that big was the reason, she expressed.

Alone with her choice, but seeking support

When returning home after the incident described above, Amelia decided to change whatever it took to lose weight. It was her choice not to involve her family, who she was convinced, did not believe in her. She signed up for a ‘healthy life’ course, realizing her need for support. She ended up attending more courses that first year. When asked about what these courses meant to her, she said, ‘I don’t think I would have made it without that help’. The implied obligation to participate and the knowledgeable instructors were essential. They provided knowledge about food and meals, and structured her physical training. Mutual support among the ‘weight-losers’ in the group gave her the feeling of ‘being in the same boat’.

Mental and physical surplus following new habits: a self-rewarding process

Amelia explained that her former competitive instinct awoke seriously when her decision to lose weight materialized. ‘There was no other resort when I – at last – started’. Soon, she started to lose weight and feel well. When asked about the most important experiences from this first year, she pointed to her surplus of energy as ‘a remarkable change, just by changing foods and eating habits’. Earlier, she could go for hours without food, then, eat enormous amounts of food in the evenings. Now she had breakfast and smaller meals every third hour.

‘I could wake up in the morning, feeling full of energy instead of feeling tired and out of sorts’. Restructuring her eating habits received most of the credit for this remarkable felt change in her body, yet strongly supported by increased physical endurance and strength from the physical training. When having the support and knowledge she needed, the weight-loss journey soon became a self-rewarding process.

Trusting established habits to keep the weight off despite temporary bodily changes

Amelia emphasized the importance of planning in order to ensure she would have her preferred food available at all times and being consistent about not overeating. She explained that the rule of ‘being ahead’ is important for preventing the return of bad habits. When asked about the amount of energy she invested in food and eating, she explained that the necessary habits were so well established at present, that she did not experience having to invest much of her energy in planning ahead. Amelia gave credit to her instructors in the ‘healthy life’ courses, not only for helping her to establish these habits, but also for giving her the advice to discontinue weighing her food after being sufficiently acquainted with the amount of food appropriate for each meal. Her story indicates that she has a firm grip on these matters. What about her pregnancy? Did that trigger a fear of permanent weight regain? The interviewer was curious. ‘I was a bit observant in the beginning’, Amelia said, but: ‘I saw it as a completely different process (not about weight) ‘. And: ‘I was quite confident that I would lose weight again when the pregnancy had passed, so I was not that worried’.

She trusted her established habits to keep the weight off for the long-term.

Living the dream and looking forward

When asked about the most important consequence of losing weight, Amelia does not hesitate: ‘The most important is that I am here with my own family and child … I live a good life, in every meaning of it’. She continues by pointing out that living such a fulfilling life is a huge change from feeling low, to the way she feels now. ‘That’s my motivation for not putting on weight’. She lives the life she has longed for.

Living the solution to weight loss for the long-term, but emotional scars still at play as a driver of comfort eating – ‘Paul’

Paul is a married man in his fifties with grown children and grandchildren. He is well educated, works fulltime, and leads a very active life in his spare time. The last weight-loss journey started eight years ago. He lost 35 kilos during the first year and stabilized himself at that weight. After years of failings, Paul has found a miracle cure, namely, a low carbo diet. At present, he is a deeply engaged and educated spokesman for this solution. Yet, it seems to be difficult to keep up with this way of living. Paul reflects on the possible connection between emotional scars and using food as comfort.

‘I Was a sugar-burner’: explaining the genesis of his weight problem

Overweight was no problem during Paul’s childhood, even though his diet at home included lots of sugar and carbohydrates. His father died at a young age, and his mother allowed Paul to decide for himself what to eat, he explained. However, he was an active boy, playing football, cycling, always on to something, considering himself a sports-boy, and a smart boy. He talked about being well integrated among his schoolmates and doing well at school.

A turning point in the story was when Paul left home. His physical activity decreased considerably and he started to gain weight: ‘In half a year, then, it just said ‘puff’ (the weight almost exploded) ‘. He led a rather sedentary life then, eating lots of chocolate and drinking sugary sodas, and when he was out with mates, he drank beer. ‘I was a sugar-burner,…’ he claimed, and: ‘Sugar addiction is the mother of all addictions, always craving more and more’. Sugary and carbo-rich foods were to blame for his (and others’) overweight. When asked about how the weight gain influenced him, he says he felt uncomfortable with his own body; he became easily out of breath and experienced the heaviness of his body slowing down his movements. ‘Hello, I was a sportsman; I could not live like that’. He began a roller coaster pattern of losing and regaining weight. After several years of pushing himself intensely on the ‘wrong’ diets and lots of physical activity, he ‘hit the wall’. In this situation, alcohol and chocolate, which previously eased his emotional troubles now and then, became a real problem. ‘I understand perfectly well that becoming addicted to sweets, alcohol, drugs, and so on, can be a kind of escape…to ease unhappiness a bit’. Paul’s turning point was seeking help for his alcohol problem, which meant never touching alcohol again.

Low-carbo diet – finding, living, and promoting a lasting solution

Paul began to educate himself about the physiology of being overweight and diets, and finally discovered the low-carbo diet, naming it ‘the lasting solution’. This discovery changed his weight journey. When Paul adhered to this diet, his appetite and the amount of food consumed regulated itself: ‘I know my body lives well with this diet; no problems with stabilizing my weight’. During this period, he educated himself for employment in a new profession and changed his workplace and tasks, which was followed by ‘feeling more in harmony with my life’, unlike the disharmony he had felt for years in his previous job.

Changing oneself is ongoing hard work, and so is saving others

Paul is still invested in living a low-carb life, and is very much ‘back on track’ living the life of an athlete, with much support from his wife and sharing this with her. It is still necessary for him to ‘be on guard’ in order to avoid falling into his old habit of comforting himself with chocolate when feeling ‘down’, which he still does sometimes. The driver in his current life is a strong commitment to helping others:

‘I want to help others who struggle with obesity. Cut through the ‘bullshit’ we have learned for the last 30 years (the official advice for a healthy diet, which also includes carbohydrates). As well-intentioned as that advice may be, it doesn’t work; we are exploding with overweight and diabetes and…’

Paul is formally educating himself within this field in order to reach his goal. This engagement also causes deep frustration with the necessity of having to spread the good news in a ‘world of lies’ about what a healthy diet means. When asked more about this strong commitment, he replies by asking himself if he really has to ‘save the world’, that is, if he has to go all in when something matters to him. Does it have to be such a struggle all the time?

Hopes for the future: finding a lasting balance in life

The interviewer and Paul share their thoughts on being in emotional balance and unbalance. Paul reflects on his burning desire for life-building powers and a potential risk for burning him out. He is sorting out what may lead him to a longed-for lasting balance in his life.

Discussion

In the discussion of important issues brought forth in the participants’ stories we aim at an interplay between deepening knowledge about the physicality of material bodies and experience thereof in the weight loss and maintenance processes, the strong transformation aspect in the stories, the struggle with health problems, and the significance of a meta-story about stigmatization in society of high weight bodies.

It seems appropriate to discuss ‘different obesities’, which not only include differences in the size of the persons with severe obesity in our study when they initiated their weight-loss journey, but also differences between their experiential horizons. These include whether or not they: had a history of being obese from childhood and adolescence onward, were physically active, and enjoyed being fast and fit, and able to move with ease. Our participants talked about their physical burden related to their high weight bodies, followed by difficulties walking upstairs, walking uphill, not being able to run, lack of energy, and experiencing being in bad shape. The three participants led active athletic lives during childhood and adolescence, then recognized their physical condition as alarming and preventing them from moving with ease in their surroundings. Hence, the functional state of their bodies had become a threat to their physical unfolding and to whom they considered themselves to be. Their bodies had turned against them.

In Collins’ study (2011), female participants who became severely obese in adulthood felt conflicted between their previous normal weight and feeling healthy as opposed to their high weight bodies and health problems during adulthood. Collins suggests that not experiencing obesity from childhood on, but as an adult, may contribute to a strong desire and decision to return to a former normality. We refer to this kind of normality as a familiar and bodily-based experience of a personal normality. The participants in our study talked about not feeling at home in their own bodies and surroundings when they were severely obese, returning to a homelike situation after losing weight, and being and feeling more fit again. As former athletes, they knew from within what it felt like to be fit and fast. Furthermore, they knew implicitly what it was like to wear oneself out through strenuous workouts, what the difference felt like in their bodies between a satisfying physical tiredness and crossing the line to exhaustion. It is likely that these types of bodily-based knowledge helped them regain a feeling of homeness and personal normality of their own bodies and world. As such, these participants seemed not to experience these aspects of their journey with anxiety about entering the unknown, but rather with the comfort of heading back home.

Being severely obese carries a stigma in a society in which a fat body is a symbol of lack of self-discipline and something socially unacceptable (Lupton, 2012). Our participants found themselves in a situation where their own bodies became a prime object of self-contempt. Although none of the three participants reported a history of bullying or open social disapproval, they revealed feelings of self-contempt for their former high weight bodies, which refers to this meta-story in the culture. It is a reasonable assumption that their extreme fear of weight regain also was anchored in this meta-story. It is also interesting that in other studies, which explored experiences of persons who had undergone weight-loss surgery, one of the aspects described was access to social arenas that were formerly closed to them. Now, this access revealed to them how stigmatized obese people were, which elicited feelings of sadness and sorrow (Natvik et al., 2013; Warholm et al., 2014). When one leaves a situation that is very demanding, there is an opportunity to access meta-perspectives and emotions, which the person earlier might have ignored in order to protect oneself. They knew, but were not fully aware of, how deeply stigmatized people with severe obesity seemed to be. We do not know how this might have affected our participants. However, it is most likely that they encountered negative attitudes toward persons with obesity; in social groups they became part of during the weight-loss process, fueling their strong desire to avoid obesity. Dominating meta-stories in the culture indicate the impossibility of being severely obese.

Together with knowledge about what it takes to avoid weight regain, this leaves weight-loss maintainers in a haunted state. The imperative to change and the decision to make it in these transformation stories depends on the double burden of severe obesity; lived experience of health concerns and limited space of action related to the materiality of high weight bodies, and the stigma of obesity in the culture. There was simply no way back, always haunted, always ‘on guard’ in the wake of the lost weight.

The three narratives are ‘quest stories’ (Frank, 2010), which are stories containing transformation. These three persons endeavored persistently and creatively to cultivate new competencies, establish new eating habits, re-establish old physical-training habits, form new relational bonds, and reinvent their lives and themselves, thereby reframing their weight-loss project and revising their hopes for the future. Their lives changed profoundly. The self-rewarding processes of weight loss and maintenance are core in these stories, boosting progress, self-esteem, and stability over time, as reported in earlier research (Collins, 2011; Hartmann-Boyce et al., 2018). McAdams and McLean (2013) point to redemption sequences in adults’ life narratives, which mark transitions from an emotionally negative situation to a positive one, and/or a positive attribution about the self. In our participants’ stories, transitions from an emotionally negative situation and self-contempt to a new, hopeful situation and self-esteem took place, where agency and self-rewarding processes seem paramount. Agency as a construct in life stories is defined by these authors (p. 234) as: ‘being able to affect change in their own lives or influence others in their environment, often through demonstrations of self-mastery, empowerment, achievement, or status. Highly agentic stories privilege accomplishment and the ability to control one’s fate’.

However, the stories are not all about transformation, but also about new and old health problems. To make their stories work, it seemed important for the participants to subordinate new problems to the resolution of old problems, a process that may have created ongoing tension. We will dwell on each of the three stories to deepen this understanding.

Paul’s story shows a deep commitment to keeping the weight off for the long-term and helping others who need to do the same. Even though Paul has shown that he deals with his weight, he conveyed uneasiness about his situation. He mentioned current urges for comfort food when feeling emotionally unbalanced. He talked about being a recovered addict, but also worrying about being fully recovered after all. Although many good things are present in his life, there seemed to be a craving to be satisfied, which may cause distress. Based on a systematic review, Greaves et al. (2017) suggested that the behavior changes required for keeping the weight off may generate experiential conflict because setting aside current habits creates a discrepancy between the new behaviors and the fulfilment of emotional needs. Hence, it may be important to be aware of the possible use of old habits to handle emotional reactions, as food and eating continue to play a role in the lives of weight-loss maintainers.

Elfhag and Rössner (2005) reviewed factors associated with weight maintenance and regain, and developed a profile characterizing ‘the successful weight maintainer’. While sustaining one’s awareness and regularity of eating habits and monitoring food, the weight maintainer manages to handle instances of relapse in a balanced way, not exaggerating it as a dramatic failure. Furthermore, her/his life is sufficiently stable, and she relies on her own strategies. In contrast to Emily’s story, addiction to self-monitoring practices and strategies related to food and eating are not themes in Amelia’s story, even though she has to be aware of keeping the weight off. She did not perceive her pregnancy as a threat to her weight-maintenance project. Amelia expressed that she is exactly where she wants to be in her life, with a caring co-habitant and her new rewarding role as a mother outweighing any threatening feelings caused by a temporary weight regain. She has the stability she needs in her life and trusts her established habits to keep the weight off for the long-term.

In Emily’s story, pushing limits and continuously transcending former sports achievements and goals was a strong driver to persevere. This self-rewarding practice provided Emily with impressive sport achievements and recognition from fellow athletes.

However, Emily’s story is also about a problematic relation to food. For several years as a young adult, she had no control of her food or eating, and hence, her weight, developing severe obesity. Now, the fear of weight-regain haunts her, and control of food and eating is a strong presence in her story. Rigid regimens to monitor food and calories and strict eating habits dominate her daily life. Her preoccupation with strict food and eating regimens is recognized as a health problem. In their review of qualitative studies on self-directed weight loss and maintenance, Hartmann-Boyce et al. (2019) identified self-monitoring strategies as helpful for keeping the weight off, but also as a source of failure and a reason for quitting the entire weight-loss project. Shame, caused by failure to follow regular rules, is highlighted. Emily’s story is not about shame or failing the weight-maintenance project. Her story shows that established habits for keeping the weight off, including self-monitoring practices, can become an obsession in the continuing fight against the long-gone severely obese body. Letting go of strict regimens, even if doing so is a seldom event, can be interpreted as a possible relapse of a former problematic eating behavior and obesity. Emily knows she has an iron will. Yet, the slightest deviation is threatening. Flexibility of the new habits, which seems necessary to maintain a healthy balance, is missing. Emily longs for a way to ease up a little in her life and seeks help, opting for changes that again will require hard work.

As already pointed to, counter-stories exist in this landscape, opposing both the medical meta-story about obesity as a disease, and the cultural norms related to obesity, directed at healing the internalized stigma from ‘sizeism’ (Calegero et al., 2018; Salas et al., 2019). As claimed by Coleman (2000), a meta-story about obesity as solely bad health and social stigma is in itself a threat to health, and this is documented in the research literature (Puhl et al., 2020). The significance of counter-stories for changing norms and eliminating oppression in society related to obesity is welcome indeed. In opposing the hegemonic story about medicalization and stigmatization, however, stories about weight loss and maintenance from severe obesity are somewhat provocative and interpreted only in light of fulfilling expected health-related norms and socially acceptable bodies; norms that need to change. In opposing the hegemonic medical story there seems to be little room for stories about health problems and any limitation following the materiality of high weight bodies, or any story that deviates from the main goal of opposing the hegemonic story. The dimension of social stigma is relevant to the interpretations of the stories from our three participants. However, this lens is neither sufficient to understand the deep sense of fulfillment following the reinvention of their lives and selves, the joy of being able to move with ease again in a lighter body, nor the continuous battle to avoid weight regain.

Methodological considerations

In this study, we have argued for the relevance of a narrative perspective in research on self-directed weight loss and maintenance after severe obesity in order to deepen the understanding of the complexity of this phenomenon. Methodological approaches to conduct and analyze the in-depth interviews were performed using a narrative approach, exploiting the possibilities of going deeply into each story. We were able to see and in detail describe important variation in the stories related to fear of weight regain, and to show that the weight loss journey meant not just transformation, but also struggling with new and old health problems. We were also able to contextualize the findings according to insights into the single participant’s situation, all of which earlier analysis did not highlight. During this process, the researchers in the team were involved in all phases, through thorough discussions and consensus on core findings, challenging each other’s expectations of findings, and discussing which roles meta-stories in the culture played in the participants’ stories.

Conclusion

In this study, stories about weight loss and maintenance as life- and identity-changing processes are presented and discussed. Self-rewarding processes are essential to these stories, boosting storytellers’ self-esteem and stability over time, and reaching goals of great importance to them. The stories are about major achievements, as well as new and old health problems, adding to the complexity of the phenomenon of losing and keeping the weight off after severe obesity. Obsession with keeping up strict regimens to control food and eating was present, as was emotional eating despite the storytellers’ controlling their weight. Their past as persons living with severe obesity still lingered in the stories; however, this past was also keeping up their weight-maintenance journeys. It was simply out of the question to return to severe obesity and previous experiences of being too heavy to move fluently and to be in a physical condition with little energy, which limited their life-space and induced self-blame. This study indicates that it may be of importance to talk about different types of obesity, not just the initial weight from which the weight loss occurs, but also the weight history. In our case, not being obese during childhood and adolescence seems to be important when it comes to the familiar feeling of homeness in a lighter body, and for owning the decision to lose weight and keep it off for the long-term.

Weight loss maintenance from severe obesity may be possible but seems to be a very demanding and never-ending endeavor. Health care workers need to know about this, and support self-care during the process. In supporting persons who want to lose weight it seems important to sort out goals that are meaningful for the individual person, their story, and the situation they find themselves in, and actively seek to empower the person. It may also be a good idea not to set the goal of losing weight as the primary one, but advice on improving health in more ways.

Stories of weight loss and maintenance from severe obesity may be considered provocative in the wake of the need for healing weight-related stigma and countering oppression in society. As already acknowledged, our point of departure is not that people living with high weight bodies must lose weight in order to live fulfilling lives. However, to ignore the suffering associated with the health-related burdens of severe obesity in people’s stories implies a failure to recognize health related problems linked to the materiality of very high weight bodies, and a failure to respect their lived experiences of this condition.

Acknowledgement

We thank the participants for sharing their stories and the professionals who recruited them.

Disclosure statement

No potential conflict of interest was reported by the authors.

Additional information

Funding

This research was supported by the District General Hospital of Førde, and Western Norway University of Applied Sciences.

Notes

1 Obesity is defined as a body mass index (BMI) ≥ 30 kg/m², while severe obesity is a BMI ≥ 35–40 kg/m². We are aware of the critique that the use of BMI to define health is a narrow, even misleading definition. Health as a phenomenon is a complex one, never resting on one aspect alone. Still, we have used BMI to communicate with health researchers, and to inform that participants in this study started out with a very high body weight.

2 The definition of long-term weight loss is maintenance of 10% of the baseline reduction for at least one year (Wing & Phelan, 2005).

3 Instead of obese persons.

4 Bariatric surgery means weight loss induced by invasive surgery, where weight loss is fast and massive according to changes in the physiology and anatomy of digestion organs. Even though it is shown that maintaining the weight loss due to surgery may involve challenges for the long-term, the process of weight loss is substantially different than self-directed weight loss and maintenance.

5 North Germanic ethnic group native to Norway

6 Questions to this main topic: Can you tell about your weight trajectory throughout life? Start where you like. Follow up: Are there any other aspects of your life circumstances that are important in your weight story? What about specific events, experiences or situations that has evolved and related to the weight loss journey, or somehow have been significant and/or meaningful? What about weight cycling, weight stability, weight plateauing/stagnation? Has your weight at any point felt like a threat to you, or your life situation? If not, can you elaborate on that? If yes, can you tell a bit more about that? Questions were used flexibly in the single, specific interview situation.

7 Fictional names.

8 Underscoring a word or an expression in the extracts from the interviews means that the participant, in the intonation during the interview, put pressure on it.