A qualitative exploration of weight management during COVID‐19

Summary COVID‐19 has been associated with worse outcomes in people living with obesity and has altered how people can engage with weight management. However, the impact of risk perceptions and changes to daily life on weight loss has not been explored. This study aimed to examine how COVID‐19 and perception of risk interacted with weight loss attempts in adults participating in a behavioural weight management programme. Forty‐eight participants completed a semi‐structured interview exploring the impact of COVID‐19 on their weight management experience. Interviews were completed via telephone and analysed using a thematic approach. Reaction to perceived risk varied, but most participants reported the knowledge of increased risk promoted anxiety and avoidance behaviours. Despite this, many reported it as a motivating factor for weight loss. Restrictions both helped (e.g., reduced temptation) and hindered their weight loss (e.g., less support). However, there was consensus that the changes to everyday life meant participants had more time to engage with and take control of their weight loss. To the authors' knowledge, this is the first study to explore the impact of COVID‐19 on participation in a weight management programme started during the pandemic in the United Kingdom. Restrictions had varying impacts on participant's weight loss. How risk is perceived and reported to participants is an important factor influencing engagement with weight management. The framing of health information needs to be considered carefully to encourage engagement with weight management to mitigate risk. Additionally, the impact of restrictions and personal well‐being are key considerations for weight management programmes.


Funding information
This research is funded as part of an MRC PhD studentship (MC_ST_U18004). AM and SS were supported by UK Medical Research Council and Scottish Chief Scientist Office core funding as part of the MRC/CSO Social and Public Health Sciences Unit 'Complexity in Health Improvement' programme (MC_UU_12017/14, MC_UU_00022/1 and SPHSU14, SPHSU16). EL was supported by MRC Skills Development Fellowship Award (MR/S015078/1).

Summary
COVID-19 has been associated with worse outcomes in people living with obesity and has altered how people can engage with weight management. However, the impact of risk perceptions and changes to daily life on weight loss has not been explored. This study aimed to examine how COVID-19 and perception of risk interacted with weight loss attempts in adults participating in a behavioural weight management programme. Forty-eight participants completed a semi-structured interview exploring the impact of COVID-19 on their weight management experience. Interviews were completed via telephone and analysed using a thematic approach. Reaction to perceived risk varied, but most participants reported the knowledge of increased risk promoted anxiety and avoidance behaviours. Despite this, many reported it as a motivating factor for weight loss. Restrictions both helped (e.g., reduced temptation) and hindered their weight loss (e.g., less support). However, there was consensus that the changes to everyday life meant participants had more time to engage with and take control of their weight loss. To the authors' knowledge, this is the first study to explore the impact of COVID-19 on participation in a weight management programme started during the pandemic in the United Kingdom. Restrictions had varying impacts on participant's weight loss. How risk is perceived and reported to participants is an important factor influencing engagement with weight management. The framing of health information needs to be considered carefully to encourage engagement with weight management to mitigate risk. Additionally, the impact of restrictions and personal well-being are key considerations for weight management programmes. What is already known about this subject • Obesity is linked to increased risk of worse COVID-19 outcomes.
• COVID-19 lockdowns and restrictions have caused changes in how the public interact with their environment, socially, and in their weight-related behaviours What this study adds • Forty-eight adults living with overweight, or obesity in the United Kingdom were interviewed about how COVID-19 had impacted their weight loss journey while participating in an online behavioural weight loss programme • The study found perception of risk, environmental and social changes, and personal wellbeing all influenced participants' weight losses.

| INTRODUCTION
Obesity has been identified as a leading risk factor for poorer COVID-19 outcomes, with higher rates of hospitalization, complications, comorbidities, and mortality with increasing body mass index (BMI). 1,2 Those with obesity-related comorbidities, such as elevated blood pressure and cholesterol, have had worse COVID-19 outcomes when compared with BMI groups in the normal range. 3,4 Evidence from Public Health England has shown that 40% of adults gained weight during the COVID-19 restrictions in the United Kingdom. 5 Given the current increasing levels of obesity in the United Kingdom, with approximately 28% of adults living with obesity, and 36.2% overweight, this provides an added layer of complexity in tackling the public health pandemic of COVID-19. 6,7 In response to the increased risk of worse COVID-19 outcomes in those living with obesity, there have been calls for better policy and action to support people with obesity to lose excess body weight and thereby reduce their risk of poorer health outcomes. 4,8,9 To support weight loss during a pandemic, it is key to consider how lifestyles have changed. Weight loss is commonly described as a journey, underlined by the Foresight report highlighting the myriad of influences on weight (i.e., policy and environmental, interpersonal, and intrapersonal factors). 10 Within the United Kingdom, lockdown models (i.e., limitations on socializing and use of public services), food supply issues, and social distancing drastically changed how people lived. 11,12 Exploring how the COVID-19 pandemic and the resultant changes to life, including how people socialized and interacted with their environment, affected weight loss journeys can provide novel insight into the interplay of health risk and perceptions, environment, and social changes.
Research has shown that COVID-19 restrictions resulted in decreased levels of physical activity and increased emotional eating, sedentary behaviour, salt and sugar intake. [13][14][15][16] These behavioural changes were related to resource availability, emotional well-being, and negative social changes (e.g., reduced social interactions, loneliness) associated with the imposed restrictions. 17 For example, in the case of physical activity (PA), an observational study using remote monitoring through implanted cardiac devices found a significant decrease in PA during the first UK lockdown, with this gradually returning to baseline 3-4 weeks post-lockdown. 13 A study by Brown and colleagues, which surveyed 543 UK adults living with obesity in May and June 2020, found 55% reported having an unhealthier diet, 61% had reduced levels of PA, and many reported a decrease in general well-being, with worse results in those who engaged in a weight management service before lockdown. 18 A similar survey of 2002 UK adults also found a negative impact on eating and PA (in 56% of adults) and an increase in perceived barriers to weight management (i.e., reporting issues with motivation and control of diet). 19 These changes were particularly evident in adults living with a higher BMI, which was associated with lower levels of PA and diet quality, and a higher frequency of overeating and snacking.
Although the above studies provide useful insights, in order to adequately support adults living with obesity or overweight to lose weight, it is important to understand their experiences during the pandemic. Qualitative studies can provide deeper insight into people's experiences, as well as the dynamics between factors influencing weight loss and well-being. Grannell and colleagues interviewed participants of a weight management intervention in Ireland to assess the role of the pandemic on the sustainability of changes and the psychosocial impact of COVID-19 on their weight loss. They found variety in responses to the pandemic in health behaviours, with low levels of awareness of the risk associated with obesity, and a negative impact on well-being. 20 This provides useful insights into how the pandemic influenced behaviour change from one hospital in Ireland. However, to our knowledge, there are no qualitative studies exploring the experience of those engaging in self-referred online weight management programmes in the United Kingdom during COVID-19. The aim of this study was to explore the impact of COVID-19 and the associated restrictions on the experiences of participants in an online behavioural weight management programme. This provides unique insight into the impact of the pandemic on adults living with overweight and obesity who are actively engaging in weight loss attempts. Additionally, given increasing understanding that obesity and overweight are a risk factor for worse COVID-19 outcomes, we wanted to understand whether this had an impact on people's motivation to lose weight or how they interacted with their physical and social environment, which could subsequently impact their weight loss success.

| Recruitment
Participants were recruited via the Second Nature online behavioural weight management programme. Participants were recruited from the paid arm in the United Kingdom. Second Nature is a 12-week online programme that uses behaviour change techniques such as self-monitoring, goal setting, and education on various lifestyle factors, including diet and PA. Participants were placed in an online group with other participants on the programme and a "health coach". The "health coach" was a qualified dietician. The group allowed participants to share experiences with peers and sent queries to their health coach. This health coach led the group through the 12-week programme by answering questions, facilitating discussion on barriers, facilitators, problem-solving, and setting objectives. 21 Throughout the programme, participants had access to their group anytime online.
Participants were emailed information about the current study and a survey by the Second Nature programme staff once they signed up. Invitation emails were sent out in waves in October, November, and December 2020. Eligibility for the study consisted of being an adult (18+ years) who had recently enrolled in the Second Nature programme (0-2 weeks), with a BMI of 25 or above at the start of the programme. If participants were interested, they emailed the researchers for further information and/or to arrange participation in the study. Participants were compensated £20 for taking part in the interview. The data were collected as part of a wider mixed-methods study investigating barriers and facilitators to weight loss, which consisted of data collected at three time points: an interview (of which the current study was a part of), social network data collection, and surveys (one at the beginning and one at the end of the project). Participants could opt to do either the surveys, the interview, or both.
Social network data were collected at every time point.

| Data collection
Participants completed a semi-structured telephone interview with MT (PhD researcher) midway through participation in the programme (approximately 4-8 weeks). Data were collected as part of a wider interview study exploring barriers and facilitators to weight loss. Table 1 shows the COVID-19-specific section of the interview schedule. The interview schedule was developed following a review of the weight loss literature and discussions with people with lived experience. This approach allowed exploring the impact of COVID-19 in different aspects of participants' lives (e.g., environment, social, personal well-being, and risk perceptions) and how participants related this to their weight loss while in the programme.
All interviews were recorded using a portable digital recording device and took place at a mutually convenient time. Consent was obtained via email correspondence or recorded before commencement of the interview. Interviews lasted 60-90 minutes. Upon completion of the interviews, the audio files were uploaded, and interviews were transcribed verbatim.

| Data analysis
Transcripts were analysed using thematic analysis. 22 First, transcripts were read, and initial codes were generated according to the interview questions and research aims. This created a preliminary coding framework that was discussed with SS and AM. Transcripts were coded using Nvivo 12. 23 Themes and sub-themes were then generated both deductively and inductively and labelled using participant's words to keep themes true to the data. To reduce bias and increase dependability, 10% of the transcripts were reviewed by a second colleague (either SS or AM) and any nuances or discrepancies were discussed and resolved. Following the generation of themes, matrices were created to view responses and frequency of themes amongst the participants.

| Reflexivity
To increase the rigour in the research, the lead author (MT) engaged in reflexive thinking throughout the research process and this should be considered while appraising the credibility of this study. 24 The data for this study were collected as part of a larger  25 Following the development of the interview schedule, two patient representatives were consulted on whether questions were clear, understandable, and holistic. During the interviews, MT also asked participants if they would like to add anything further about their experiences and if novel items emerged in the interviews this was explored. An effort was made to ensure spacing between interviews to allow for reflection and learning from each interview. To try and ensure participants felt comfortable, interviews were arranged at a mutually convenient time, building rapport, encouraging discussion through active listening, and the interview schedule was used flexibly to allow novel ideas to be explored. The study has followed the COREQ guidance for reporting qualitative research. 26 T A B L E 1 COVID-19 questions from interview schedule  where varying COVID-19 rules and restrictions were in place. Participant information can be found in Table 2.
Regarding their weight loss journey, participants had a mix of opinions and insights as to how the COVID-19 pandemic and restrictions influenced their weight status, the decision to begin the programme, and progress during the programme. Table 3

| Access to facilities
Weight-related behaviours (i.e., diet and PA) were impacted by the restrictions through changing access to different environments.
Reduced access to facilities acted as both a barrier and facilitator to participants. Difficulty in accessing healthy food for meals (i.e., due to shortages of food in supermarkets) and exercise facilities (e.g., gym, swimming pool) acted as barriers: "I remember going to the supermarket, couldn't find anything really to eat… it was just a case of buying anything that would make some sort of a meal. And then the personal training stopped as well and the swimming." (p125, female, 38) While others found the closure of certain facilities reduced temptation and made it easier to lose weight: "I actually found that easier for me because I wasn't tempted by you know, restaurants and things like that.
And I did actually lose weight over the lockdown rather than gaining it, so that was actually quite good." (p109, female, 35) While others discussed socializing and how they engaged with their environment had ultimately changed, all participants reported an increased engagement with green space generally and specifically for social activities:

| Adapting activities
"I think before coronavirus, we'd sort of meet people outdoors, but we'd also do a lot of meeting in restaurants and that side of thing. I think the balance is now more meeting up with people outdoors" (p124, male, 40)

| Home
There was less consensus on the impact of spending more time at home on weight loss. Some participants found this worked as a barrier to their progress by reducing their PA, taking care of family members (e.g., children, elderly), adapting to more time at home, and having greater access to temptations:  ing throughout their weight loss. It is, therefore, crucial to explore how to avoid such negative reactions while promoting positive ones (i.e., encourage positive engagement with weight management to mitigate risk associated with obesity), and to understand why some who experienced the hindering emotions and behaviours became motivated while others did not. One theory that may offer insights into the disparity of the health messaging becoming a motivating factor in the current study is the protection motivation theory. This theory suggests that a combination of our threat appraisal (i.e., COVID-19 risk and weight status, and how these link) alongside our coping appraisal (i.e., self-efficacy and skill level to mediate the threat) influence our behaviours. 27,28 With the participants in this study, a discrepancy in threat appraisal or coping appraisal could have led to differing reactions. Both could have influenced how health messages were delivered to participants. 29 In the field of weight management, while health risks of excess weight are common knowledge, it is often the early diagnosis that prompts behavioural and lifestyle changes, suggesting the risk of ill-health is not perceived as a strong enough threat to warrant change. 30 The participants in this study had all paid to take part in the weight loss programme and chose to contact the research team to take part, which may limit the range of views gathered as part of this research.
Similarly, the sample overall had a BMI in the lower obesity range, and there was a lack of ethnic diversity and men in the study. In terms of methodology, the use of telephone interviews may have impacted the data we collected, as rapport with the interviewer is more difficult to achieve than in a face-to-face setting. However, the interviewer MT did not identify any difficulties gaining rapport with participants. This approach may also have supported participants to be more candid due to feelings of anonymity. Research has shown that when telephone and in-person interviews are compared, they are of similar duration and detail, and participants report finding it easier to focus on the voice rather than the face of the researcher and feeling less judged and uninhibited when on the telephone. 39-41

| Study strengths
The study provides novel insights into how the COVID-19 pandemic affected weight loss journeys of participants in a behavioural weight loss programme in the United Kingdom. This is useful for making suggestions on how to manage public health in any future pandemics as well as for general weight management services. Such suggestions can be used for general weight management practice and policy and can arguably also be applied to groups who face similar limitations outside of COVID-19. For example, those who are trying to lose weight or services who are trying to engage with harder-to-reach groups (i.e., those with reduced access to resources and socializing, with little time, and those with ill-health).

| Implications for policy and practice
Based on the findings of this research, considerations for policy and weight management services are summarized in Table 4. These are implications for policy and practice, which are applicable to weight can impact those around them. These suggestions could apply in a post-COVID setting to those with reduced social contact (e.g., due to location), understanding health risks associated with weight and behaviour, and in future pandemics.

| CONCLUSIONS
The current study found that knowledge of obesity as a risk factor for worse COVID-19 outcomes had varying effects on participants' weight loss. The framing of health information regarding increased risk to COVID-19 needs to be considered carefully during the pandemic and post-COVID-19 times. The study showed participants had varying perceptions of risk, which could be attributed to how the health information was shared and their understanding of the relationship between obesity and health. There was also differing positive (i.e., increased motivation) and negative (i.e., feelings of shame, avoidance behaviours) to risk. Further research exploring these differing reactions would be useful in understanding how to promote health behaviour change in post-COVID times. Similarly, participants' experiences were variable with the consensus that the emotional demands of the pandemic due to uncertainty and social changes acted as an obstacle. Largely, participants felt that changes in access to facilities and having more time to understand and engage with their weight management supported weight loss.