Experiences of using Very Low Energy Diets for weight loss in consumers and providers: Qualitative Findings

Abstract

Background: Obesity and overweight are both, risk factors for numerous chronic diseases and thus, represent a high cost, both population wide and on a personal level. In Australia, this cost and the prevalence of obesity and chronic disease is increasing, despite public health measures to reduce them. Quantitative evidence has demonstrated that Very Low Energy Diets (VLEDs) offer the most effective long-term non-surgical weight loss outcomes and are cost effective, however they are rarely prescribed in practice. Reasons for this are often subjective and not easily encompassed with quantitative methodology. They include: they are unpleasant to use and difficult to adhere to, are unsafe and may induce increased weight regain or yo-yo dieting with concomitant psychological distress and will not embed the skills needed to maintain a lower weight in comparison to losing weight slowly. The overall aim of this thesis was to understand the lived experiences and perspectives of people who have undertaken a VLED for weight loss and those who have lost weight with a VLED and how this affected their experience of weight maintenance. Additionally, clinician experiences and perspectives of treating obesity in practice were investigated to more fully understand how the context of primary care informs their choice of intervention, including their use of VLEDs. Given the exploratory nature of this research a qualitative approach was undertaken to gain the understanding of a multiplicity of perspectives to enhance and deepen the investigation. The weight maintenance experiences of using VLEDs for weight loss and the clinician experiences were explored within the Australian context. Methods: Four studies were conducted to achieve this aim. Chapter 2 (Study 1) consists of a systematic review and synthesis of existing qualitative research that describes the perspectives and experiences of people who have undergone a VLED for weight loss. In order to extend knowledge beyond the active VLED weight loss stage, Chapter 3 (Study 2) consists of a qualitative study that used semi-structured interviews to explore womens’ experiences after undertaking a VLED. This study explores the period of time (1 or 2 years) after the participants had lost a significant amount of weight on the VLED and how this affected their experience of weight maintenance. This qualitative study was conducted as a sub-study to a randomised controlled trial conducted in Australia, in which VLED was the treatment arm of the trial. To help further the enquiry into why VLEDs are not routinely prescribed for weight loss at a community level and how the context of primary care influences treatment Chapter 4 (Study 3), explored accredited practicing dietitians’ (APDs’) perspectives and practices regarding obesity and obesity interventions, including the use of VLEDs and MRPs. This study was undertaken in the private practice context in Australia. To test how utilising VLEDs for weight loss could translate from the research context into practice Chapter 5 (Study 4) outlines a case study. This case study outlines a journey of a patient who took part in a translational pilot study which was embedded as an adjunct to an existing public health outpatient setting. Results and discussion: Study 1 found that VLEDs were generally well accepted and positively viewed by users. Adherence was facilitated by group meetings, rapid weight loss and ease of use. Barriers to adherence, such as temptations and social occasions, were overcome by avoidance and distraction strategies. Study 2 found that undertaking a VLED for weight loss conferred advantages during maintenance that previous weight loss attempts had not. Significant weight loss gave confidence and a desire to manage weight. Complete cessation of usual diet during a VLED helped break bad habits and introduce new helpful habits and self-efficacy in the ability to lose weight remained, even in those who had regained weight after the VLED. Study 3 found that the dietitians in this study preferred patient centred care and would prescribe VLEDs in certain circumstances. However, significant systemic barriers constrained effective treatment and success was predicated on working outside of the systemic barriers. Study 4 found that removing systemic barriers and treating patients as an adjunct to their usual care could effect significant change. Conclusion: In conclusion, this thesis makes an original contribution to research in obesity and provides an in-depth understanding of the experiences of treating obesity with a VLED. This study highlights that many of the negative views held by both patients and clinicians may be unfounded. The experiences of using VLEDs for weight loss can potentially translate to other settings outside of Australia. It also uncovers that there is a gap between the current management of obesity in Australia’s healthcare system and evidence-based practice for obesity. This thesis also outlines a case of successful treatment in this population within a model of care that eliminates the systemic barriers faced by many primary healthcare practitioners in the community. The findings in this thesis can inform future direction for developing feasible evidence-based and patient centred models of care at a primary health, community level for individuals who are affected by obesity.