Overall, the participants in this study found that limiting caloric intake and/or increasing caloric expenditure contributed to their weight control. Additionally, cognitive practices or thought patterns motivated them to continue with their weight loss and maintenance. The themes included (a) nutrition: increase water, fruit, and vegetable intake, and be consistent with both the timing and content of meals; (b) physical activity: at least three times per week, follow and track an exercise routine that brings variety and enjoyment; (c) restraint: practice restraint by limiting and/or avoiding unhealthy foods; (d) self-monitor: plan meals, and track calories/weight-loss progress; and (e) motivation: participate in motivational programs and cognitive processes (thoughts and reminders) that affect weight-control behavior. The specific practices that relate to each theme are shown in . In the descriptions of each theme, below, representations of the practices related to the theme are included. Each individual practice is not discussed separately because of space limitations.
Theme 1: Nutrition
Increasing water, fruit, and vegetable intake, and having consistency with both the timing and content of meals were nutritional factors that contributed to weight-control success. Although we know that eating fruits and vegetables and limiting unhealthy food is an important part of weight loss and maintenance, qualitative data allow researchers to examine not only what, but also how others have adopted the practice into their lives. Examples of how participants made healthy choices and increased their fruit and vegetable intake include quotes such as (a) “I just stay in the produce aisle․… That is all good stuff․… It works for me․… I have maintained my weight for 12 years”; (b) “Eating salad can make me full in my head, but not in my stomach․… I have to have a salad with lunch and dinner”; (c) “I eat yogurt, strawberries, and fruit”; (d) “I only buy foods that are healthy for me. Even if I snack, it is raw or dried fruits, or maybe raw vegetables”; and (e) “I eat a lot of Cheerios, Frosted Mini Wheats, Raisin Bran, Kashi Go Lean, Grape Nuts.” Participants (n = 4) also mentioned the practice of limiting their caloric intake while eating out, noting that they chose healthier choices such as fish or poultry, and salad instead of pasta, or used low-fat menus, such as Weight Watchers. One gentleman in military service said, “I avoid eating what is fried. Even at the Army, I try to watch what I eat.”
Another practice was to avoid processed foods and to eat organic, whole foods; natural foods; and fruits and vegetables (n = 5). Examples included drinking skim milk and eating light yogurt, using Splenda or other artificial sweeteners instead of sugar, using low-fat butter, eating a large amount of vegetables to fill up before dinner, and filling cabinets with healthy foods. Last, participants used the practice of eating about the same thing every day (n = 5), as reflected in the following comments: (a) “I shop for similar foods every time I go to the store”; (b) “I consistently eat the same thing for breakfast․… It does not change. Lunch is grilled chicken from McDonald’s with no mayo [mayonnaise] … diet soda”; (c) “I eat about the same thing every day. This way I know the calories in my meals and snacks”; and (d) “I eat breakfast, lunch, dinner, and three snacks regularly. I keep a schedule of eating․… I don’t just eat when I am hungry. I know this works because I lost the weight and have kept it down.”
Several participants chose to increase their water intake (n = 9) to have more energy, and to fill up on water to avert cravings. Several (n = 7) also read nutrition labels on food packages to limit their carbohydrates; to look for fiber content; and to determine fat, calorie, carbohydrates, sodium, whole wheat/grain, and protein content. One person kept “proteins and fats around 40% and carbs [carbohydrates] around 20% to 30%” to help with weight maintenance.
Theme 2: Physical Activity
Participants found that following and tracking an exercise routine that brought variety and enjoyment at least three times per week was important for weight control. A variety of responses about how physical activity could be incorporated into a daily routine were discussed. The responses were divided nearly equally between those who exercised at home (n = 9), worked out at a gym (n = 9), and walked outside for exercise (n = 8). The home exercisers typically used a treadmill, hand weights, and exercise videos, and said things such as (a) “I exercise about 3 to 5 times a week. I run on the treadmill at my house, about 3 days a week․… I work out for 30 minutes a day when I’m trying to maintain my weight and about 60 minutes when I am trying to lose weight”; (b) “I work out from 10:30 to 11:00 with a ‘Fit TV’ program called ‘Gilad’”; (c) “I do an abdominal video every day”; (d) “I have a rebounder [a mini trampoline] at home. I do it 30 to 60 minutes 3 times a week for muscle and cardio.”
Those who worked out at a gym (n = 6) typically chose cardio equipment (elliptical, treadmill, stair–treadmill) rather than an organized exercise class: (a) “Every day, even for 20 minutes, I work out alone. I do 20 to 30 minutes of treadmill, or elliptical, or stair–treadmill”; (b) “I go to the gym at least three times a week, for about 60 to 90 minutes․… I do combined cardio and a nautilus circuit”; and (c) “I go to the gym three times a week. I swim and use the treadmill for about 1.5 hours․… I go with a couple of friends.”
The outside walkers (n
= 5) followed a regular exercise routine, ranging from one mile to three miles per day. One woman walked three times a week for three miles, usually early in the morning. She said, “I started walking to lose weight. I continued because it was taking off inches, and it takes my appetite away.” Another said that she walked every day, “even on Sunday.” Others responded: (a) “I walk my dog three times a day”; (b) “I try to walk 10,000 steps a day with a pedometer”; and (c) “I walk almost everywhere. I walk to work and at work․… I walk every day for 40 minutes to one hour, to and from work.” Another woman responded,
I walk regularly. I try for daily, at least 6 days a week. I walk a mile every day, alone or with someone or with my dog. In the summer, I walk all along the lake (more than a mile). My dog gets exercise and I do, too. Walking is free and the nearest health club is about 60 miles.
Most participants exercised by themselves, but some reported that it was helpful to work out with other people (n = 6). One man who always exercised with someone else said, “My brother works out with me Monday, Wednesday, Friday, a coworker is with me Tuesday and Thursday, and I may have clients working out with me any day during the week.” Some worked out with their families, such as a man who took his daughter with him to the gym on the weekends, or one who took his two young sons (ages 4 and 6) with him to the basement for a workout as his wife walked beside him on the treadmill. Having a workout partner seemed to be a form of accountability, as well as making the exercise more enjoyable. If people found an exercise routine they enjoyed doing, they were more likely to stick with the plan; for example, “I really enjoy exercising․… I like how it makes me feel. I like that I am doing my body good, burning calories, and keeping my muscle tone up.” One person summed it up this way: “I am always trying to improve. I keep reaching for more by diversifying and changing things. I keep my core of exercises constant but add reps [repetitions] and modify it to challenge myself.”
Theme 3: Restraint
Participants found that not only did they need to engage in new behaviors and thoughts to change their weight, but they also needed to practice restraint in their meal patterns by limiting and/or avoiding unhealthy foods. The majority found that limiting carbohydrates helped them achieve this goal. Some replaced high-calorie foods or drinks with those that have fewer calories, such as choosing “sherbet over ice cream,” or peanuts over candy bars; for example, “I keep peanuts around the house. I use them for a snack. They are high calories, but are better than a candy bar.” Another participant agreed that “nuts are good fats and protein that will keep you from getting hungry.” Other examples of limiting carbohydrates and fat were: (a) “I stay away from all white products … no flour, bagels, pasta. I eat spinach pasta”; (b) “Instead of putting four sugars in my coffee, I put two”; (c) “I used to eat Fruity Pebbles or Cocoa Puffs for breakfast; now I eat healthier”; (d) “I used to eat out often, but I stopped. The food is fattening”; (e) “Avoiding eating out helps me maintain my weight … when you make your own food, you know what is in it”; and (f) “I used to eat a whole pizza, but now I occasionally have a slice or two.” Some participants used the practice of limiting the amount of unhealthy food in the home to avoid slipping into previous patterns of unhealthy behavior (n = 7). Comments included: (a) “I might have soda if we go out, but I do not keep soda in the house. If it is not there, I can’t have it”; (b) “I avoid the snack aisle [in the grocery store]. I won’t bring bad food into the house”; and (c) “Because I am single, if I bake a cake, I have to get it out of the house.”
Participants (n = 14) allowed themselves to eat small amounts of some unhealthy foods, but practiced restraint so as to maintain weight. One participant previously drank six or seven sodas per day and three cups of cappuccino, but she replaced those poor practices with eating Lean Cuisine (a brand of low-fat, low-carbohydrate frozen entrees) and drinking water instead. Other participants said, (a) “I don’t deny myself if I want something badly. I ‘pick my battles’ with food”; (b) “I splurge on pumpkin pie, but avoid whipped cream on the side”; (c) “I like chocolate, so I allow myself to have some every now and then. I might eat one Hershey’s Kiss, or a few M&Ms [two different kinds of chocolate candies]”; (d) “Once in a while, I have steak if I crave red meat․… I know it is fine to have a treat․… I know it works because my cholesterol and blood pressure are great and I haven’t gained weight”; (e) “I try to eat well Monday through Thursday, then I can eat what I want Friday to Sunday. I don’t deprive myself of things I enjoy”; and (f) “German chocolate cake is my favorite … I have one small slice․… I don’t deny myself.”
Last, a common practice that participants used to practice restraint was portion control (n
= 12). By eating smaller portions throughout the day, these individuals were able to maintain their weight. One woman who lost and maintained a loss of 125 pounds said,
I weigh and measure everything I eat. Everything … because it is all about portion control. I am broken and I don’t work like you do, like a normal person does, and I don’t stop when I am full. Four ounces is a drop in the bucket; it means nothing. I could eat a 25-ounce steak every day and not be full.
Others had additional strategies for restricting their portions, such as: (a) “I buy 100-calorie packs”; (b) “I put portions on a smaller plate and use smaller portions so that I don’t eat as much, but I think I have more food”; (c) “I snack periodically throughout the day. I rarely have a big meal․… I’m an artist, and I’m usually working on a lot of things at once”; and (d) “If I want to eat something that is unhealthy, I eat it slowly and with small bites.” One participant controlled portions by using the palm of his hand as a reference size for steak, fish, and chicken. He adjusted his portions to eat until he was full, but not overstuffed, and said, “This worked for me and it was not extreme. It was a change and I stopped overeating. I know it worked because I lost the weight and maintained the weight loss without perpetual exercise or starving myself.” A woman stressed the importance of portion control in snacking by saying,
I never bring a full package of anything out of the kitchen. I have chips in the house because my husband eats them. If I need to have some, I will just take a handful and bring it out of the kitchen. I will not bring the whole bag with me.
Another woman mentioned that she did not clean her plate at every course, and said, “I do not allow the food on my plate to be touching, because if it is touching, I have too much on my plate.” These practices helped participants practice control with their eating patterns.
Theme 4: Self-Monitoring
The focus of self-monitoring was planning for meals, as well as tracking calories and tracking progress toward the desired weight goal. Related to portion control, participants reported that they planned their meals for the day in advance to avoid impulsive behavior. Having a system of planning ahead for meals and before grocery shopping was important to monitoring weight. Some individuals (n
= 5) mentioned preparing food in advance or taking food with them, planning for meals to avoid overeating. One man planned what he was going to eat in advance by preparing a large quantity of food on weekends and freezing it in meal-sized portions. One woman planned her meals in advance by thinking about her next meal. She said,
After I eat breakfast, I am thinking about my next meal. Do I want a protein shake or something like nuts, or cheese and crackers? I’m always thinking about my next meal. I try to stay ahead of it, so I don’t wait for the last minute and grab something that is not as good for me. I pack my lunch the night before so that it is already prepared when I get to work.
To help with planning for shopping at the grocery store, participants (n = 6) used the following practices: (a) “I go grocery shopping after dinner․… I mentally prepare to see food I can’t buy—junk foods like candy bars and black licorice. I avoid ‘impulse’ grocery shopping”; and (b) “To shop well at the grocery store, I have to keep my daughter at home [because] she puts sweets in the cart.” On woman spoke of her weekly trips to the grocery store, where she watched what other people were putting into their cart that might be appealing—especially the fruits. She took her time (about 30 to 45 minutes) when going grocery shopping, and looked for low-calorie or low-fat selections.
Included in this theme is also the need to monitor the number of calories eaten at each meal, and to keep track of weight-loss progress (n
= 10). Participants tracked the number of calories to become aware of what they were eating and to improve their eating practices. Writing tools included journals, food diaries, calendars, and computer logs in which participants recorded daily food intake and weekly weight. One participant explained:
I write a lot. I document my exercises․… I write what I did during the day with the date and time. I document what I eat․… If I had a bad interaction with someone, I document that. I document almost everything. I will write “Don’t eat sweets for the next three days.” If I go back and read it, I know I can’t have it.
Other participants discussed how they kept track of what they ate and the importance of keeping a journal to give them time to “stop and think” and review what they had consumed (food and water) for the day. One participant used a journal to keep track of the amount of water she drank each day. Another woman said,
I gauge the amount of certain nutrients: proteins, carbs, fat, and calories. I write it all down daily when I am trying to lose weight․… It makes me very focused on my portions and amounts. I am conscious of things that go into my mouth. If I don’t focus on writing it, my weight stays the same.
To keep track of weight-loss progress, participants weighed themselves between three and seven times per week. One woman kept the scale in her kitchen, which made it convenient for her to weigh herself regularly. Weight control required monitoring of meals and weight to keep a healthy balance. A participant summarized: “If I see increased weight … I will pay a little more attention to what I’m eating over the next couple of days, or not have sweets, or take the dog for a 10-minute-longer walk each time.”
Theme 5: Motivation
Motivation was a contributing factor to success in losing and maintaining weight, and this theme could be divided into two categories: (a) participating in motivational programs, and (b) engaging in a cognitive process (thoughts and reminders) that affected weight-control behavior. Programs mentioned included Weight Watchers, Jenny Craig, LA Weight Loss, TOPS (Take Off Pounds Sensibly), and Nutrisystem, and participants (n
=4) found that accountability kept them motivated through group support. Participants (n
= 4) also looked for information in television shows (i.e., the Biggest Loser), on the Internet (Weight Watchers), and in magazines (GNC, Fitness, Shape
) for inspiration and ideas on how to maintain weight. However, the most reported practice for maintaining motivation was through cognitive processes (n
= 44), which affected weight-control behavior. Participants often reminded themselves how much better they felt because they were contributing to their health. They reported that they wanted to keep their weight under control to reduce cholesterol levels, blood sugar, and blood pressure. Some (n
= 15) enjoyed more energy and took pride in their health, which kept them motivated, as expressed in these statements: (a) “When I am energized in the morning, and I don’t need a nap all day, I think about that this is how I want to continually feel․… Energy is a motivator to keep me on track”; (b) “I feel empowered and proud of myself because I am in charge of my health. I feel better physically and emotionally. I used to feel weighed down at the end of the day”; (c) “I think about how much happier I am now that I’ve lost the weight․… It motivates me and makes me feel good”; and (d) “It is a gift to be able to put anything in my closet on at any moment. I like that I can walk up and down stairs without passing out. I have more energy from my weight loss.” One woman who was previously embarrassed about her weight said,
I remind myself of the things I could not physically do that I can do now, like paint my toenails. Not being able to do that made me feel old and worthless․… I was afraid to ice skate because I thought I might fall and not be able to get up.
To motivate themselves to keep their weight under control, some participants (n
= 9) said they looked at previous pictures of themselves or thought about how they used to look when they were at an unhealthy weight. One example is,
I think about my self-esteem, my image in the mirror. I think about it every day when I’m shaving or combing my hair. You see a picture of yourself: “Do I look better now in the mirror or in the picture?” If I look better now, then I am doing the right thing.
Examples of other things said by participants include: (a) “I think of the way I used to look and how I was not happy”; (b) “I have bad memories of my body image, or not feeling comfortable when I was heavy, and when I’m tempted to eat more or not go to the gym. I keep those things in mind”; (c) “I took a few Polaroids [photographs] each month … to see how much weight I had at the start and the end of the month”; and (d) “I was thin when I was younger, so I look at my pictures from when I was thin. I look at them to remind myself what I want to get back to before I had four kids. I think about being happy back then.”
Related to this practice, participants also thought about fitting into fashionable clothes, and were motivated by the thought of fitting into a smaller size (n = 9). One woman who was pleased with her new size said, “Nothing feels as good as fitting into your clothes.” Others expressed similar motivations: (a) “I go to the mall and look at smaller sizes, and think I want to fit in petite. I’m motivated because the petite clothes look better than women’s, and I want to fit into them. I am motivated to work harder”; (b) “I think about fitting into my favorite pair of jeans. I felt great when I fit into them. The size that I fit in now makes me feel good about myself”; and (c) “I say to myself, ‘If I don’t do good, then I can’t buy that.’ It is really fun to try on the clothes and fit into a regular size. I use it as a motivator.”
To help keep diet and exercise goals in mind, participants thought about people who were overweight as a self-reminder to keep their own weight under control (n
= 6). One said,
Seeing people who are overweight is a reminder [to stay on track]․… It is heartbreaking to think about being so overweight. I am grateful that I was able to make changes to get out of it. I remember how it felt. It makes me conscious that I do not want to go back there, and it helps me stay on my goal. I feel bad for them.
Seeing others who were unhealthy was a motivator for some to eat well and exercise, as expressed in the following statements: (a) “When I see big people in the supermarket, even big kids, I am reminded to take my time and put healthy items in my cart”; (b) “Everyone averts their eyes from an obese person. I cry when I see them … because I know they are in so much pain, and that is part of me”; and (c) “I work around a lot of obese people, and when I look at them, it triggers me to stick to my plan.”
Finally, participants thought about what they were eating to help them stay with their plan (n = 5). Many used this strategy, particularly when they were making plans to eat out. They reminded themselves to stay away from fast food, which is unhealthy. It was important for them to eat healthy and not to overeat, especially avoiding desserts or skipping appetizers. A participant who ate out socially said, “I have to remind myself to eat well.” Some participants became aware of what they were eating before putting the food into their mouths; for example, one woman who used this weight-loss strategy consistently said she became more “mentally aware of what I’m eating․… I care more than I used to. I didn’t realize before that I needed to lose weight.” Another example was, “I think about what I eat. Am I really hungry, or am I eating just because I am bored?” A motivated participant summarized that she stayed engaged by thinking of losing weight in increments. She said, “I didn’t lose 140 pounds. I lost one pound 140 times.”