1 00:00:01,110 --> 00:00:03,689 Hi, everyone. Thank you for coming tonight. 2 00:00:03,690 --> 00:00:10,650 So as Emory said, I'm Jamie Horton, voice senior researcher in Health Behaviours at the Department of Primary Care. 3 00:00:10,920 --> 00:00:14,910 And I spend the vast majority of my working life doing systematic reviews. 4 00:00:15,180 --> 00:00:19,620 And so today I'm here to talk to you about findings from three qualitative, 5 00:00:19,620 --> 00:00:25,710 systematic reviews we conducted looking at adults experiences of trying to lose weight on their own. 6 00:00:27,330 --> 00:00:36,630 I'd be remiss if I didn't start with acknowledgement. So the three analysis I'm presenting to you today all emerged from my Ph.D. research, 7 00:00:36,900 --> 00:00:40,380 which was helped by lots of people, including the lovely Anne Murray. 8 00:00:40,800 --> 00:00:47,459 And this work was supported by the National Institute for Health Research, which is essentially the research arm of the NHS. 9 00:00:47,460 --> 00:00:50,370 So I don't have any conflicts of interest to declare in that regard. 10 00:00:51,630 --> 00:00:57,240 So what I'll talk about today a very quick introduction to what we mean when we talk about qualitative 11 00:00:57,240 --> 00:01:03,180 synthesis and then some background into the research that I'll be going into on the self management of weight. 12 00:01:03,750 --> 00:01:09,450 I'll talk you through the aims and the methods of the three reviews, their key findings and their implications. 13 00:01:09,450 --> 00:01:14,730 And my understanding we have a mixed audience today, so some of you will be here because you're interested in the weight side side of things, 14 00:01:15,150 --> 00:01:18,870 some because you're possibly more interested in the qualitative methodology. 15 00:01:19,140 --> 00:01:23,700 I'll try to cover both of those and mainly through work examples of the reviews. 16 00:01:25,620 --> 00:01:34,589 So what we really mean by qualitative, systematic reviews are syntheses is the process of pooling qualitative and mixed method research 17 00:01:34,590 --> 00:01:39,420 data and then drawing the conclusions regarding the collective meaning of that research. 18 00:01:40,110 --> 00:01:44,939 So what I started off in systematic reviews, I was very much on the quantitative side of things, 19 00:01:44,940 --> 00:01:51,840 so I was looking at mainly randomised controlled trials, their effect measures, and then pooling those using statistical methods. 20 00:01:52,230 --> 00:01:58,260 Qualitative, systematic reviews are a very different story and I'd say in recent years they're becoming more and more frequent. 21 00:01:59,070 --> 00:02:05,520 The first time I came across them was when we were commissioned to do some work by Nice, who sets the clinical guidelines in this country? 22 00:02:05,850 --> 00:02:11,070 And they wanted us to look at lifestyle weight management programs for overweight and obese adults. 23 00:02:11,280 --> 00:02:16,710 And so that means things like Weight Watchers or Slimming World and whether or not GP should refer patients to these. 24 00:02:17,070 --> 00:02:24,149 And the first review they asked us to do was to see how much weight people lost on these programs and other outcomes, and that was quantitative. 25 00:02:24,150 --> 00:02:29,010 But then they were also very interested in the barriers and facilitators to these programs. 26 00:02:29,010 --> 00:02:32,999 So there's no point in doctors having this as their suite of things to offer if the 27 00:02:33,000 --> 00:02:36,180 doctors aren't going to offer them or if the patients aren't going to take them up. 28 00:02:36,450 --> 00:02:37,859 And that's when we did a qualitative, 29 00:02:37,860 --> 00:02:44,520 systematic review to look at people's experiences in attending or not attending these programs and doctor's experiences as well. 30 00:02:44,790 --> 00:02:45,569 So qualitative, 31 00:02:45,570 --> 00:02:52,230 systematic reviews have really for me come from that place of trying to understand people's experiences with health care interventions. 32 00:02:52,440 --> 00:02:58,050 And sometimes that means they're pairing up with quantitative, systematic reviews, and sometimes they stand on their own. 33 00:02:59,670 --> 00:03:04,050 Now there are a few steps to conducting a qualitative synthesis. 34 00:03:05,370 --> 00:03:11,489 The first few on this are very similar whether or not it's a qualitative or quantitative systematic review. 35 00:03:11,490 --> 00:03:15,330 So with a systematic review, we go out, we come up with a research question. 36 00:03:15,630 --> 00:03:18,210 In our field, it's usually about a health care intervention. 37 00:03:18,720 --> 00:03:24,930 We establish a team who's going to help us look at that question because very few people go out and do a systematic review on their own. 38 00:03:25,020 --> 00:03:32,550 It's a pretty substantial undertaking. We'll agree exactly what we're going to do at the outset, and usually we do this through publishing a protocol, 39 00:03:32,850 --> 00:03:38,100 and this is really to make sure partly that we're all on the same page in terms of moving forwards, 40 00:03:38,100 --> 00:03:42,870 but also to make sure we are trying to reduce bias and be as transparent as possible. 41 00:03:43,110 --> 00:03:46,800 Because the idea of a systematic review is kind of the keys in the word systematic. 42 00:03:47,070 --> 00:03:51,540 It should be transparent, it should be reproducible. So we should be able to publish our protocol. 43 00:03:51,720 --> 00:03:54,900 And if someone wanted to go and copy it, they should be able to do that. 44 00:03:55,650 --> 00:04:02,160 We then conduct searches, so we search numerous databases and also some other types of literature, which I'll talk about in a bit. 45 00:04:02,730 --> 00:04:08,820 For relevant studies, we screen them down for the ones that are actually relevant to that research question we're trying to answer. 46 00:04:09,150 --> 00:04:13,770 And then we go and we extract the data, the information that we want from those studies. 47 00:04:14,100 --> 00:04:21,419 So up to there, exactly the same. If it's a quantitative or qualitative systematic review, at the bottom, things get a bit different. 48 00:04:21,420 --> 00:04:25,770 And that's the part where we bring all of our findings together and then of course, write it up. 49 00:04:26,400 --> 00:04:33,059 So down here is these three steps. Here are how we synthesise the data in the three reviews I'm going to be talking about. 50 00:04:33,060 --> 00:04:41,280 And that's a method called thematic synthesis that I will come back to in a bit and I'll go through these steps with you one by one. 51 00:04:41,280 --> 00:04:48,120 But it is also worth acknowledging that thematic synthesis is not the only way to do a qualitative synthesis. 52 00:04:48,570 --> 00:04:54,660 There are lots of them. In a review done a few years ago where they went out and looked at all of the qualitative syntheses that had been done. 53 00:04:54,960 --> 00:04:59,300 They identified these nine unique methods. For the sake of all of us, I'm. 54 00:04:59,490 --> 00:05:03,810 Going to go through each of those today. But if you are interested in learning more about them, 55 00:05:04,140 --> 00:05:09,680 that's probably the first a good first port of call to get a little bit more information on what each of those might look like. 56 00:05:09,690 --> 00:05:12,149 And they also link to some examples of each of those. 57 00:05:12,150 --> 00:05:17,100 But as I said, for us, we used thematic synthesis and I'll go into the reasons behind that in a bit. 58 00:05:19,050 --> 00:05:27,330 So moving on from that, as I mentioned this, these reviews came out of my Dphil research and my Dphil research was specifically 59 00:05:27,330 --> 00:05:33,420 interested in looking at self-directed weight loss in adults with overweight or obesity. 60 00:05:33,430 --> 00:05:37,440 So there are a few reasons why I picked this as the area I was interested in. 61 00:05:37,740 --> 00:05:44,940 We know that over two thirds of adults in the UK have overweight or obesity and this puts them at an increased risk of a range of health conditions. 62 00:05:45,480 --> 00:05:51,870 We also know that at any one time about half of the adults in the UK are trying to lose weight and we know that the 63 00:05:51,870 --> 00:05:58,169 vast majority of them are doing this without any sort of professional support or support from a formal programme. 64 00:05:58,170 --> 00:06:04,050 So rather than losing weight with help from their GP or their practice nurse or through going to Weight Watchers, 65 00:06:04,350 --> 00:06:09,080 they are really deciding this is something I want to do and they're setting out and doing it on their own and we can. 66 00:06:09,300 --> 00:06:15,300 This makes sense to us when we think about most people we know trying to lose weight. They are indeed embarking on these self-directed attempts. 67 00:06:15,960 --> 00:06:21,390 Now, paradoxically, even though the vast majority of these people who are trying to lose weight are doing it in self-directed means, 68 00:06:21,390 --> 00:06:28,260 if you look at the research, the focus of the research is very much on weight loss efforts that involve some sort 69 00:06:28,260 --> 00:06:33,330 of professional support or support from an intervention such as Weight Watchers. 70 00:06:33,960 --> 00:06:35,670 There are a number of reasons for this imbalance. 71 00:06:35,880 --> 00:06:40,560 Partly it's just easier to study people if they are part of an intervention because they're showing up to it. 72 00:06:40,770 --> 00:06:43,920 You can track them much easier. It's much easier to identify them. 73 00:06:44,340 --> 00:06:47,610 Also, of course, there's more impetus, for example, 74 00:06:47,610 --> 00:06:54,000 from the health care sector to study interventions delivered by doctors from the commercial sector to study commercial programs. 75 00:06:54,270 --> 00:06:59,640 And so this group of people who are trying to lose weight on their own were really pretty much under-researched. 76 00:07:00,030 --> 00:07:05,129 And when we did our systematic reviews on behalf of Nice and we looked at all these formal weight loss interventions, 77 00:07:05,130 --> 00:07:11,880 it felt to me like it was probably time to look at another aspect of that picture, which were people who were essentially going it alone. 78 00:07:13,020 --> 00:07:21,120 So the aim of this research was to hone in on the cognitive and behavioural strategies that people use to try to control their weight. 79 00:07:21,540 --> 00:07:26,400 And the reason this came out is kind of the big research aim is the lack of research in this area generally. 80 00:07:26,410 --> 00:07:30,260 So what I was interested in doing through my Ph.D. was trying to figure out, okay, 81 00:07:30,270 --> 00:07:37,260 what strategies that people are using seem to be associated with success, seem to be helpful, which strategies are not helpful? 82 00:07:37,830 --> 00:07:43,770 But it was impossible to do that without actually first having a list of the strategies that people were using. 83 00:07:44,790 --> 00:07:47,909 And I just wanted to quickly give a shout out to this picture here. 84 00:07:47,910 --> 00:07:51,690 And the image credit here is that it's from the World Obesity Society Image Bank. 85 00:07:51,690 --> 00:07:54,750 So working in this field for quite a few years now, 86 00:07:55,860 --> 00:08:00,839 you often see presentations with pictures of adults living with overweight or obesity that are quite stigmatising. 87 00:08:00,840 --> 00:08:03,980 That is definitely what we tend to see in the media a lot. 88 00:08:04,230 --> 00:08:12,360 And the World Obesity Society Image Bank is a collection of free to use open copyright images that are hopefully not stigmatising. 89 00:08:12,360 --> 00:08:20,610 So just to give a shout out there. So in terms of deciding, okay, I need to map these strategies, how on earth am I going to do it? 90 00:08:21,660 --> 00:08:28,110 That was the first step of my PhD. It was to develop something that we called the Oxford Food and Activity Behaviours taxonomy, 91 00:08:28,620 --> 00:08:34,949 and that was basically generating a list of all the strategies that it seemed like people might use to control their weight. 92 00:08:34,950 --> 00:08:41,220 And we did this by using a grounded framework approach, looking at commonly used weight loss resources, 93 00:08:41,700 --> 00:08:45,120 coding them, so picking out all the strategies from them. 94 00:08:45,120 --> 00:08:52,229 Those of you on the qualitative course may have already heard about framework a little bit and then mapping those on to existing behaviour change, 95 00:08:52,230 --> 00:08:56,730 taxonomies and theories, consulting with colleagues who are primarily academics. 96 00:08:57,000 --> 00:09:02,310 And we ended up with this list of 117 strategies grouped into 21 domains. 97 00:09:02,940 --> 00:09:06,630 So just a few examples of those to get a sense of what I mean. 98 00:09:07,080 --> 00:09:13,739 So for example, goal setting was a domain that involves setting goals in terms of how much weight 99 00:09:13,740 --> 00:09:17,280 you wanted to lose each week or how many calories you're going to eat each day, 100 00:09:17,520 --> 00:09:22,889 or how many steps you were going to take. So all kind of things that weren't necessarily surprising, 101 00:09:22,890 --> 00:09:28,140 but being able to categorise all of them and then link them into broader descriptive themes. 102 00:09:29,100 --> 00:09:32,249 Now those steps all yielded all these strategies, 103 00:09:32,250 --> 00:09:39,840 but at that point we were still very much aware that all the data we'd gotten at that point had come from existing resources. 104 00:09:39,840 --> 00:09:44,210 Whether or not those be interventions or kind of academic thinking on weight loss. 105 00:09:44,550 --> 00:09:50,490 And what we're really interested in is what people were doing outside of academia, outside of these formal interventions. 106 00:09:50,490 --> 00:09:53,190 So we wanted to make sure that we looked at this from another angle. 107 00:09:54,090 --> 00:09:58,799 We couldn't really do a quantitative survey of this because we didn't know which strategies. 108 00:09:58,800 --> 00:10:05,100 We didn't. So we couldn't just go out and ask people and therefore we wanted to do some qualitative research investigating this topic. 109 00:10:05,580 --> 00:10:11,720 But it felt like something that just interviewing 20 people, you're probably still not going to get a full range of strategies. 110 00:10:11,730 --> 00:10:12,360 So we thought actually, 111 00:10:12,360 --> 00:10:19,030 let's start out with a review of the qualitative literature to see what's come out in a range of different qualitative studies. 112 00:10:20,130 --> 00:10:26,460 And that brings me on to the first of these qualitative syntheses that I'm going to be discussing today. 113 00:10:27,150 --> 00:10:30,240 So in my Ph.D., I said, okay, this is great. 114 00:10:30,240 --> 00:10:35,550 One of the chapters of this Ph.D. is going to be a qualitative, systematic review to check if I'm missing any strategies. 115 00:10:35,560 --> 00:10:43,230 So the questions that asked were what cognitive and behavioural strategies do people report using in self-directed weight loss attempts? 116 00:10:43,650 --> 00:10:45,959 What language do they use to describe these strategies? 117 00:10:45,960 --> 00:10:51,170 And that was really to make sure that if in the end we did end up using this taxonomy to ask people what they were doing, 118 00:10:51,180 --> 00:10:58,920 we were using language that made sense to people and also some questions around the barriers and facilitators to implementing these strategies. 119 00:10:59,220 --> 00:11:05,070 So for example, something like self-monitoring, if people are using it, what are they finding useful about it? 120 00:11:05,070 --> 00:11:08,660 What are they finding not useful about it? What should we bear in mind in the future? 121 00:11:08,670 --> 00:11:13,860 Because of course you have your individual strategies, but they can all be implemented in very different ways. 122 00:11:14,610 --> 00:11:21,390 Now, we weren't expecting that many studies to come up, and so this is what I'd set out three very simple questions, 123 00:11:21,990 --> 00:11:30,629 and we published it in a paper in Obesity Reviews, which gave an overview of the strategies we found, but it actually felt a very incomplete process. 124 00:11:30,630 --> 00:11:33,150 So journal articles very, 125 00:11:33,150 --> 00:11:39,540 very limited on their space and there was actually quite a lot of rich data and more studies than we were originally expecting. 126 00:11:39,540 --> 00:11:45,670 So we ended up doing some more synthesis on the back of this work and those looked at specific groups of strategies. 127 00:11:45,900 --> 00:11:47,370 And I'll talk about those as well. 128 00:11:47,370 --> 00:11:54,839 So we did one that delved into the data on self-monitoring and we chose self-monitoring because the data was so rich in this field, 129 00:11:54,840 --> 00:11:57,870 reflected such a variation of experiences. 130 00:11:57,870 --> 00:12:03,000 And a lot of those experiences were very negative. So we felt like that really deserved some attention. 131 00:12:04,020 --> 00:12:10,319 And the other, which I will come on to, was reframing, and that's a new strategy that emerged as part of this review. 132 00:12:10,320 --> 00:12:15,120 So that hadn't come through in any of the intervention materials we'd looked at in any of the academic literature. 133 00:12:15,120 --> 00:12:21,000 But actually when we read participant accounts of what they were doing, this was a cognitive strategy that they were employing. 134 00:12:23,040 --> 00:12:29,699 So when we go back to thinking about our different steps of conducting a qualitative, systematic review right at the beginning, 135 00:12:29,700 --> 00:12:36,240 when we think about generating our research question and definitely when we're putting together a protocol, we think about our inclusion criteria. 136 00:12:36,630 --> 00:12:40,830 If you're doing a quantitative, systematic review, you typically use a framework called PICO. 137 00:12:41,070 --> 00:12:45,450 If you're doing a qualitative, systematic review, the most common framework to use is spice. 138 00:12:45,750 --> 00:12:50,010 And this is really important because this helps you narrow down what studies you will include to make 139 00:12:50,010 --> 00:12:54,240 sure that they're all similar enough that they're actually going to be a useful thing to synthesise. 140 00:12:54,720 --> 00:12:59,280 And so we were interested in studies conducted in community, in primary care, 141 00:12:59,730 --> 00:13:04,490 in adults who had attempted or were attempting to lose weight through behaviour change. 142 00:13:04,800 --> 00:13:09,780 And our specific interest was the strategies that they were using in their self-directed efforts to lose weight. 143 00:13:09,780 --> 00:13:16,920 And so what we were definitely not interested in were program evaluations and we sifted through loads and loads and loads of those. 144 00:13:17,190 --> 00:13:21,870 So a lot of the randomised controlled trials in this area and a lot of the commercial interventions have 145 00:13:21,870 --> 00:13:26,340 a qualitative study alongside them that ask about people's experience of that particular intervention. 146 00:13:26,610 --> 00:13:31,500 That wasn't what we were interested in. We were interested in people who had not experienced any of these interventions 147 00:13:31,710 --> 00:13:34,590 and they were talking about what they did essentially off of their own back. 148 00:13:35,580 --> 00:13:40,110 We didn't restrict studies in terms of comparisons and in terms of our evaluations. 149 00:13:40,110 --> 00:13:45,209 We included only qualitative studies. So that means we didn't include kind of large surveys or anything like that. 150 00:13:45,210 --> 00:13:50,370 Mainly what we were looking at were studies which primarily used 1 to 1 interviews 151 00:13:50,370 --> 00:13:55,020 or focus groups to elicit patient experiences and participant experiences. 152 00:13:56,790 --> 00:14:00,749 So searching for qualitative literature, for any of you thinking of doing a qualitative, 153 00:14:00,750 --> 00:14:04,740 systematic review, this is one of the tricky and sticking points. 154 00:14:05,100 --> 00:14:09,420 When we're searching for randomised controlled trials in large databases, 155 00:14:09,810 --> 00:14:17,760 there is a whole set of terminology and syntax that has been developed by experts to help us search for this and we can just plug in that filter. 156 00:14:17,760 --> 00:14:21,090 And there you go. Qualitative literature is not the same. 157 00:14:21,300 --> 00:14:25,709 This is partly because we are looking at such a wide range of methods and also 158 00:14:25,710 --> 00:14:29,580 because people use such different language to describe the same methods. 159 00:14:30,210 --> 00:14:37,170 So we did our database searches, but we also did a few other things to try and capture more studies that might be relevant. 160 00:14:37,170 --> 00:14:41,910 And so one of the things that we know is that studies tend to cite other studies that are like them. 161 00:14:42,150 --> 00:14:49,230 So we did a lot of forward and backward citation screening, which basically means using something like Google Scholar or Web of science, 162 00:14:49,620 --> 00:14:53,099 plugging in the article that we knew was relevant to us and looking at all the 163 00:14:53,100 --> 00:14:57,030 studies that had cited that article and all the studies that that article cited, 164 00:14:57,300 --> 00:15:01,920 and just kind of going through that. Way to. To see if we were missing anything. 165 00:15:01,920 --> 00:15:09,659 And we also looked at grey literature. So that stuff that hasn't been published in academic journals, whether it be conference abstracts or here, 166 00:15:09,660 --> 00:15:16,379 we also search through dissertations and a lot of people's PhDs involved qualitative analysis. 167 00:15:16,380 --> 00:15:22,920 And actually the pages ended up being probably the richest source of data we had because they had tended 168 00:15:22,920 --> 00:15:27,270 to have these extensive appendices where they just have the whole transcripts of their interviews, 169 00:15:27,270 --> 00:15:30,300 which certainly isn't something you'd find in a published journal article. 170 00:15:30,720 --> 00:15:33,780 So that was quite different from doing a quantitative review as well. 171 00:15:35,800 --> 00:15:36,940 With systematic reviews. 172 00:15:36,940 --> 00:15:45,460 We always report the steps that we go through in terms of the number of studies we identified, record screened and how many we ended up including. 173 00:15:45,880 --> 00:15:49,150 This is a pretty boring thing and it's a lot of numbers I won't go through in detail. 174 00:15:49,150 --> 00:15:53,350 But basically from starting out with around 3000 references, 175 00:15:53,350 --> 00:16:01,060 we ended up with 31 included studies which represented just over a thousand participants across those 31 studies. 176 00:16:03,150 --> 00:16:06,479 In terms of data extraction. So this is where we've done our screening. 177 00:16:06,480 --> 00:16:12,660 We've identified the cities that we want to include, and now we have to go and actually take the information out of them that we are interested in. 178 00:16:13,380 --> 00:16:17,400 This was done independently by two people, mainly by me and Anne Marie. 179 00:16:17,730 --> 00:16:21,560 And the reason behind that is that we all see different things in different studies. 180 00:16:21,570 --> 00:16:26,010 So if you just have one person do it, that's totally fine if that's all you can manage. 181 00:16:26,310 --> 00:16:29,969 But certainly we found places where she'd pick up something that I hadn't picked up, 182 00:16:29,970 --> 00:16:35,640 and particularly because this is somewhat subjective when it comes to saying, is that a self-management strategy or not? 183 00:16:35,880 --> 00:16:38,130 It was really useful to have two of us looking at it. 184 00:16:38,880 --> 00:16:45,120 So we extracted our self-management strategies, the general characteristics of the studies and also quality assessment. 185 00:16:45,120 --> 00:16:49,570 And I will talk through that in more detail too. So quality assessment. 186 00:16:50,220 --> 00:16:57,780 All systematic reviews should be using some sort of established tool to look at whether or not the studies they are including are rubbish. 187 00:16:58,140 --> 00:17:03,180 So a key part of a systematic review is not just saying, okay, this, studies found this and all together this suggests this, 188 00:17:03,180 --> 00:17:08,580 but it's trying to look at each individual study and say, How much do I actually trust what these people are telling me? 189 00:17:08,910 --> 00:17:15,120 The more you do systematic reviews, the less trusting, unfortunately you get of the scientific literature. 190 00:17:15,120 --> 00:17:19,949 And here I'd say that was no exception. The more studies you read and the more times you use these critical appraisal 191 00:17:19,950 --> 00:17:23,040 tools which really get you in the mindset of where there might be weaknesses, 192 00:17:23,370 --> 00:17:32,310 unfortunately, the more weaknesses you find. So we used a tool developed by the Joanna Briggs Institute to look at qualitative literature. 193 00:17:32,580 --> 00:17:39,450 We didn't exclude studies if we thought they were of low quality, but we just bore that in mind when we were interpreting their conclusions. 194 00:17:39,450 --> 00:17:45,480 And it was certainly something that we paid a lot of attention to in the limitations section of our own papers. 195 00:17:47,040 --> 00:17:53,279 So I just thought, especially for those of you on the course, but also for those of you who don't know that much about qualitative methodology, 196 00:17:53,280 --> 00:17:57,430 it might be useful to see an example of the type of questions we're asking for each of these studies. 197 00:17:57,450 --> 00:18:01,350 So we wanted to see a clear statement in terms of the aims of the research. 198 00:18:01,560 --> 00:18:06,510 We wanted to see that qualitative methods were appropriate, that the research design was appropriate, 199 00:18:07,080 --> 00:18:10,630 that the recruitment strategy was appropriate to the aims of this research. 200 00:18:10,650 --> 00:18:19,140 That means at the beginning of these studies, people set out and they said, I want to learn about men's experiences of losing weight through exercise. 201 00:18:19,680 --> 00:18:23,100 And then how did they go out and actually identify these people? 202 00:18:23,310 --> 00:18:26,610 This was a place where a lot of our studies fell down. 203 00:18:27,420 --> 00:18:31,440 They just didn't recruit people in a way that actually suited their aims. 204 00:18:31,440 --> 00:18:34,350 So in this example, we said, no, 205 00:18:34,590 --> 00:18:39,660 this study didn't use an appropriate recruitment strategy because their original question was about weight loss in men, 206 00:18:40,260 --> 00:18:46,830 and then not enough men replied. So they just changed their whole scope and included women too, which wasn't what they'd set out to do. 207 00:18:47,730 --> 00:18:53,190 And then they didn't involve the men who underwent screening there. So yeah, not not a great story in terms of their recruitment. 208 00:18:53,190 --> 00:18:58,260 I won't name and shame them. Was the data collected in a way that was sensible? 209 00:18:59,190 --> 00:19:02,759 Another really key point that some of you will have been learning about in your course is 210 00:19:02,760 --> 00:19:07,800 the relationship in qualitative research between the researcher and the participants, 211 00:19:08,040 --> 00:19:14,820 and you want to make sure that your studies are considering this. And this was another place where a lot of our studies really fell down. 212 00:19:15,240 --> 00:19:22,680 So this is acknowledging that the person who is interviewing in most cases in these studies, they their own views, 213 00:19:22,680 --> 00:19:30,900 their biases are going to reflect on how they report their results, but also possibly on the responses the people they're interviewing are giving. 214 00:19:31,170 --> 00:19:34,350 And so you want to see in qualitative studies that people are doing that. 215 00:19:34,380 --> 00:19:39,180 Unfortunately, it doesn't happen all that often. You want them to take into account. 216 00:19:39,180 --> 00:19:44,100 Ethical considerations, at a minimum have gone through an ethics board, 217 00:19:44,100 --> 00:19:47,729 but also to get some sense that they didn't just treat it as a tick box exercise. 218 00:19:47,730 --> 00:19:52,080 This is a sensitive issue and you want it to feel like people have actually thought that through. 219 00:19:53,070 --> 00:19:59,390 Next point where a lot of studies fell down was on data analysis and whether or not it was sufficiently rigorous. 220 00:19:59,400 --> 00:20:03,830 Most of the time it was just impossible to tell because no one really told us what they did. 221 00:20:03,840 --> 00:20:11,010 It was kind of like a black box. We did these interviews and then obviously there must have been hundreds of pages of text, lots of information. 222 00:20:11,010 --> 00:20:15,569 Somehow they got to their results and these themes and we just didn't know what 223 00:20:15,570 --> 00:20:19,020 happened in between those two points if more than one person was involved. 224 00:20:20,700 --> 00:20:24,480 And a real issue here, too, was if people didn't report any quotes. 225 00:20:24,780 --> 00:20:31,680 So you'd be surprised how many qualitative papers we found where people would say what they found, but they didn't give a single quote to back it up. 226 00:20:32,100 --> 00:20:38,130 And that made you think sometimes, is this really what they found or is it just what the researcher hoped they'd found? 227 00:20:38,370 --> 00:20:42,630 And so they wrote it. And I actually don't know if I trust what they found or not. 228 00:20:42,870 --> 00:20:45,960 A lot of times researchers are doing things for very, very good reasons. 229 00:20:46,260 --> 00:20:49,989 Sometimes they're doing them for not so good reasons, like to inform a funding application. 230 00:20:49,990 --> 00:20:53,790 And so if you're not seeing quotes, you're seeing statements, you don't know how they match up. 231 00:20:53,790 --> 00:20:59,010 It's just difficult to evaluate how much that's a reflection of the participants actual experiences. 232 00:20:59,550 --> 00:21:03,860 And finally, what's the research value? But we did say yes for every single study for that. 233 00:21:05,450 --> 00:21:12,500 So in terms of coding our strategies, I won't go into this in too much detail because it's quite dull for those of you who aren't going to do it. 234 00:21:12,950 --> 00:21:24,109 But we basically had a word form which had there it is there a little extract from it, a list of all of our domains, definitions of them. 235 00:21:24,110 --> 00:21:26,959 And then if a study had something that fell into that, 236 00:21:26,960 --> 00:21:32,720 we'd extract the verbatim text next to it and the page numbers so that we could then use that when we were doing our synthesis. 237 00:21:33,050 --> 00:21:39,200 So for example, here for Budding, which was about basically performing your target behaviours with another person, 238 00:21:39,200 --> 00:21:44,179 we extracted the text from this study of a participant stating If I'm committed to somebody else, I will do it. 239 00:21:44,180 --> 00:21:48,860 But if it's for myself it's very hard, especially when it's cold and dark in the winter to go out and do anything. 240 00:21:49,100 --> 00:21:55,430 If I had a buddy, I'd do it for them as much as for me. So illustrative quotes that we extracted wherever they came up. 241 00:21:56,630 --> 00:22:03,170 And the other thing that we were definitely looking for here were strategies that didn't fall within our pre-established list. 242 00:22:03,590 --> 00:22:12,320 So if we identified any of those, we'd extract that text as well, and then we'd expand our framework or expand our taxonomy accordingly. 243 00:22:12,890 --> 00:22:16,280 And we did that based on the principles of thematic synthesis. 244 00:22:16,290 --> 00:22:19,340 So I'm going to go into that in a bit more detail. 245 00:22:19,880 --> 00:22:24,740 Thematic synthesis, for those of you who are familiar with thematic analysis, is very, very similar. 246 00:22:24,740 --> 00:22:29,390 It's basically just extending thematic analysis to use it in systematic reviews. 247 00:22:29,720 --> 00:22:35,090 What that means practically is that the first thing you do is you go through and you line by line code. 248 00:22:35,090 --> 00:22:39,379 You can do this in In-vivo, which is specialist software for qualitative research. 249 00:22:39,380 --> 00:22:41,030 You can do it the old fashioned way, which I do, 250 00:22:41,030 --> 00:22:46,580 because I really like highlighters where I just read it and I underline the things that seem relevant and I take notes in the margins. 251 00:22:46,820 --> 00:22:50,990 I originally was an English literature major, and I cannot escape that mode of thinking. 252 00:22:51,950 --> 00:22:58,040 And so once you've done your line by line coding, you then go back and you look at those lists of codes and you gather them in descriptive codes. 253 00:22:58,340 --> 00:23:05,419 So, for example, if I was doing this on self management strategies, I might have style, underline software and underline food, 254 00:23:05,420 --> 00:23:10,410 diary, etc. and that might all sit under a descriptive theme of self-monitor and more generally. 255 00:23:10,910 --> 00:23:16,520 And then you go on to probably the most interesting part, which is interpreting your third order theme. 256 00:23:16,530 --> 00:23:22,309 So you're looking at these descriptive themes that the content in them and thinking how they linked together, where they might sit. 257 00:23:22,310 --> 00:23:31,070 And this is where the real kind of I'd say creativity comes into some regard before that you're doing more descriptive and 258 00:23:31,070 --> 00:23:36,810 here you're actually trying to build on what you've found and turn it into something more meaningful than just a summary. 259 00:23:37,970 --> 00:23:43,870 And that really coincided nicely for us. And the reason we chose it was because it coincided nicely with building the taxonomy. 260 00:23:43,880 --> 00:23:50,930 So those first sort of themes were identifying and these strategies that came up that weren't covered by the taxonomy and then synthesising them 261 00:23:50,930 --> 00:23:58,100 into groups of related strategies and then thinking about whether or not do we need to add a new domain to capture this cognition or behaviour. 262 00:23:59,510 --> 00:24:07,520 So in terms of our included studies, 30 odd of them sampling methods weren't great. 263 00:24:08,000 --> 00:24:12,350 11 of the studies didn't specify. Six of them is convenient sampling. 264 00:24:12,350 --> 00:24:17,420 And often this meant they just didn't recruit the number of participants they needed or the type of participants they needed. 265 00:24:17,960 --> 00:24:23,510 And in terms of the method of data collection, the majority of them. So 20 of the studies were using individual interviews. 266 00:24:23,780 --> 00:24:28,490 We also had some using focus groups, some using a combination and two studies which were quite interesting studies, 267 00:24:28,790 --> 00:24:38,570 doing qualitative analysis of web content. So going on to chat forums or people's blog posts and analysing that content through a qualitative lens. 268 00:24:40,220 --> 00:24:46,070 Quality assessment wasn't great and Murray and I were quite harsh on most of these studies. 269 00:24:46,070 --> 00:24:51,230 The majority stated their aims and using appropriate design presented valuable information. 270 00:24:51,470 --> 00:24:54,860 However, as I said before, recruitment was a real issue for a lot of these, 271 00:24:55,280 --> 00:24:58,579 as was demonstrating that they'd considered the relationship between the 272 00:24:58,580 --> 00:25:03,920 researcher and the participants and reporting a rigorous method of data analysis. 273 00:25:04,400 --> 00:25:09,170 And approximately half demonstrated that they'd looked at ethical issues and provided a clear statement of findings. 274 00:25:09,170 --> 00:25:13,249 So that's not a great picture of that overall research in this field. 275 00:25:13,250 --> 00:25:15,590 And that definitely limited what we were able to say, 276 00:25:15,590 --> 00:25:20,990 because you can only be as confident in your findings as you are in the studies that you're taking those findings from. 277 00:25:22,790 --> 00:25:28,699 So we mapped the number of studies coded against each domain. I'm not expecting you to look at this other than in detail, 278 00:25:28,700 --> 00:25:35,090 other than to say all of the domains that we've come up with in our original categorisation were covered. 279 00:25:35,870 --> 00:25:40,009 The most commonly used one was restrictions. But this was a lot of information. 280 00:25:40,010 --> 00:25:46,729 This was more information than we were expecting to get. And in the context of one paper, we weren't able to say much about the individual domains. 281 00:25:46,730 --> 00:25:53,420 So what this looked like was for regulations, restriction statements such as people experience negative attitudes, 282 00:25:54,110 --> 00:26:00,920 feelings of deprivation, which were presented as challenges to maintain and use of those strategies and things about falling off the web. 283 00:26:01,110 --> 00:26:06,510 I'm writing that up. I felt myself die a little bit inside cause I thought, Oh, but we have all this rich data, we have all these quotes. 284 00:26:06,750 --> 00:26:08,760 We can't do anything with them. Which is why we went on. 285 00:26:08,760 --> 00:26:16,469 Did the subsequent analysis only thing that people generally felt quite positive about for the rest of these, 286 00:26:16,470 --> 00:26:21,390 they either felt mixed or actually that having had predominantly negative experiences was scheduling 287 00:26:21,390 --> 00:26:26,190 people really when they were talking about strategies that had to do with scheduling quite positive. 288 00:26:26,430 --> 00:26:31,710 So viewed as a way in which to establish a route sustainable routine with one participant explaining, 289 00:26:31,950 --> 00:26:36,600 You just got to get into that schedule and it's automatic and it really makes it easier when you do have a routine. 290 00:26:36,840 --> 00:26:42,390 If I don't have a routine, God knows I don't have an idea what things would look like because it would just be so sporadic. 291 00:26:43,440 --> 00:26:52,650 And also of note, we identified two new domains that we hadn't come across in our coding previously by looking at this qualitative research. 292 00:26:52,920 --> 00:26:57,299 The first of those was reframing and we actually did a subsequent review of that, which we'll talk about. 293 00:26:57,300 --> 00:27:03,900 And reframing is the concept of people changing the language or the way they think about a weight loss 294 00:27:03,900 --> 00:27:09,780 attempt or the behaviours that go into that weight loss attempt in order to either enhance their success, 295 00:27:10,020 --> 00:27:14,639 to make it less of a negative experience or to make it easier to maintain. 296 00:27:14,640 --> 00:27:17,400 And I will get on to examples of that shortly. 297 00:27:17,400 --> 00:27:23,180 And the other was self experimentation and that was people basically actively doing essentially experiments on themselves, 298 00:27:23,250 --> 00:27:26,670 saying this week, I'm cutting out carbohydrates, I'm going to see what happens to my weight. 299 00:27:26,670 --> 00:27:29,879 If it doesn't work, I'll do something else. If it does work, maybe I'll stick with it. 300 00:27:29,880 --> 00:27:33,090 So using themselves as a science experiment. 301 00:27:34,720 --> 00:27:39,310 So key findings from Review one were that the most commonly covered types of strategies are 302 00:27:39,310 --> 00:27:43,650 the ones we have to be careful or we can't say the ones that participants most commonly used. 303 00:27:43,750 --> 00:27:47,950 We can say the ones that researchers most commonly reported on were restrictions, 304 00:27:47,950 --> 00:27:52,480 self-monitoring, scheduling, professional support and weight management AIDS. 305 00:27:53,110 --> 00:28:01,060 And with the exception of scheduling, as I mentioned, most people had mixed or negative feelings about implementation of these strategies. 306 00:28:02,710 --> 00:28:04,780 And also interestingly, from looking at all of these, 307 00:28:04,780 --> 00:28:10,660 we found that there was a variation in the strategies that people used based on the point they were in their weight management attempt. 308 00:28:10,960 --> 00:28:16,000 So it seemed like when people were in their acute weight loss phase of, okay, I want to get the weight off as quick as I can. 309 00:28:16,270 --> 00:28:22,839 They were focusing on only one or two strategies and then when they were getting into the ends of those attempts or thinking, okay, 310 00:28:22,840 --> 00:28:24,550 now I just want to try and keep the weight off, 311 00:28:24,790 --> 00:28:28,809 they were starting to get more and more strategies that they were using as part of their everyday life. 312 00:28:28,810 --> 00:28:32,680 So a definite shift and something we saw in more than one study in that regard. 313 00:28:34,150 --> 00:28:36,580 And as I said, two new groups of strategies were added. 314 00:28:37,240 --> 00:28:42,460 So going on to review to and why we decided to look specifically at self-monitoring in more detail. 315 00:28:42,910 --> 00:28:48,190 Self-monitoring is pretty ubiquitous in weight loss attempts, and it's certainly ubiquitous in weight loss interventions. 316 00:28:48,190 --> 00:28:53,650 So there are very few weight loss interventions that won't tell you to weigh yourself and to record what you eat. 317 00:28:53,770 --> 00:28:56,920 And a lot of them will tell you to record your physical activity as well. 318 00:28:57,520 --> 00:29:00,669 And when you look at the observational data, 319 00:29:00,670 --> 00:29:08,170 it looks like people who are successful at losing weight and who are successful at keeping the weight off seem to weigh themselves more frequently. 320 00:29:08,500 --> 00:29:10,000 And so than people think, Oh, that's great. 321 00:29:10,000 --> 00:29:13,540 We can just tell people to weigh themselves more and it'll work and everyone will lose weight and keep it off. 322 00:29:13,780 --> 00:29:15,850 And that absolutely isn't the case. 323 00:29:16,720 --> 00:29:23,530 So studies have found that self monitoring works for some people and it doesn't work for other people and we don't really know why. 324 00:29:23,710 --> 00:29:25,750 So that was one of the reasons we wanted to look into this. 325 00:29:26,050 --> 00:29:30,790 But also a lot of the studies that had looked at self monitoring from a qualitative angle had done so. 326 00:29:30,790 --> 00:29:37,900 One, it was part of a formal intervention, and you might think that that experience would be quite different from doing it on your own. 327 00:29:38,050 --> 00:29:43,630 So you don't have anyone there who's helping you interpret your weight changes, you don't have anyone who's trying to do it at a certain time of day. 328 00:29:43,870 --> 00:29:49,570 It's different than doing it as part of a formal intervention. So we thought what we wanted to look into that a bit more as well. 329 00:29:50,770 --> 00:29:55,810 So the questions we're asking here is what forms of self monitoring are used within weight management attempts? 330 00:29:56,050 --> 00:30:02,830 What are the roles of self undoing within those attempts? And we were also interested in the mechanisms through which self monitoring works. 331 00:30:02,830 --> 00:30:07,149 So in some cases it does seem to work, it seems to facilitate weight loss, in others it doesn't. 332 00:30:07,150 --> 00:30:11,320 And what are the differences? What are the things influencing those mechanisms? 333 00:30:12,700 --> 00:30:16,989 So methods here we focus just on those studies from review one that talked about self 334 00:30:16,990 --> 00:30:21,910 monitoring and that was a group of 22 studies and we used an interpretive approach, 335 00:30:21,910 --> 00:30:26,770 which means and I'm going to have to read it verbatim because otherwise I say interpretation too many times, 336 00:30:27,040 --> 00:30:31,389 reinterpreting interpretations to interpret courage, development of new insights and concepts. 337 00:30:31,390 --> 00:30:37,540 So this is looking at not only the participant quotes, but also the ways in which they'd been interpreted by the authors. 338 00:30:38,320 --> 00:30:41,020 And so again, here we used thematic synthesis, 339 00:30:41,680 --> 00:30:47,589 so we identified and coded first order themes and synthesise our second order themes through an inductive approach. 340 00:30:47,590 --> 00:30:53,469 So we just said, let's see what's in the data without trying to put any of our already known thoughts on it. 341 00:30:53,470 --> 00:31:00,550 I'm sure we still did absolutely do that. And then we interpreted third order themes with some help through. 342 00:31:01,870 --> 00:31:06,549 So there we go. Inductive and third order themes helped through thinking about existing theories. 343 00:31:06,550 --> 00:31:11,470 And there are two things that we drew on here. One was a psychological theory of self regulation. 344 00:31:11,770 --> 00:31:15,490 This is often posited to be the thing that makes self-monitoring work, 345 00:31:16,090 --> 00:31:20,469 and it's basically about a feedback loop where you get this information, you use it to then regulate your behaviour. 346 00:31:20,470 --> 00:31:24,280 So that's a very simplified version of it. And the other which I was interested in, 347 00:31:24,280 --> 00:31:32,169 because so much of the data that we found here was linked to shame was looking and morality came out of this self-monitoring data, 348 00:31:32,170 --> 00:31:40,360 which isn't necessarily what you'd expect. I was interested in also looking at kind of a broader societal lens and therefore drew on Food CO and 349 00:31:40,360 --> 00:31:47,470 his model of good citizenship and essentially morality and science and how that all pulls together, 350 00:31:48,130 --> 00:31:55,000 which I will again not bore you with, but just to know those are the two lenses that we use when we are trying to make sense of what we found. 351 00:31:56,770 --> 00:32:01,989 So three main themes came out of these reviews and these are those third order themes. 352 00:32:01,990 --> 00:32:06,790 So when we actually put our thinking caps on and thought about, okay, we've seen what it describes, but what does it mean? 353 00:32:07,450 --> 00:32:10,870 The first of those was self-perception and emotions. 354 00:32:11,620 --> 00:32:17,469 So this was the idea that participants felt that self-monitoring was really helping them get to know themselves, 355 00:32:17,470 --> 00:32:19,450 and this tended to be quite an emotional process. 356 00:32:19,450 --> 00:32:27,130 So an example here from a Taiwanese study of a female participant saying, I feel that my body is talking to me and I listen to its voice. 357 00:32:27,310 --> 00:32:32,830 And she was talking about that within the context of weighing herself and trying to figure out what was going on. 358 00:32:34,320 --> 00:32:39,389 However, this also linked to some very hard things for people. 359 00:32:39,390 --> 00:32:42,720 So one woman stated, Recording my food intake is the hardest thing. 360 00:32:42,960 --> 00:32:45,990 Maybe it's the ultimate ownership of what I'm doing. 361 00:32:46,830 --> 00:32:50,940 And another participant stated, When genes don't fit, you're scared to get on. 362 00:32:50,970 --> 00:32:53,460 I used to weigh myself. I don't anymore. 363 00:32:53,940 --> 00:32:59,190 And one of the things from the observational literature that you look at is if you look at people losing weight, 364 00:32:59,460 --> 00:33:04,020 when they start to stop losing weight, they also start to stop weighing themselves. 365 00:33:04,410 --> 00:33:11,129 And a lot of times this is interpreted in the academic literature as meaning it must be weighing themselves that made them lose weight. 366 00:33:11,130 --> 00:33:14,640 And so they've stopped weighing themselves. So this is why they're gaining weight. 367 00:33:15,840 --> 00:33:20,380 The data in this study, as you might expect, actually shows something very different, which is that people know themselves. 368 00:33:20,580 --> 00:33:25,320 They knew they were starting to gain weight, whether it be through the fit of their genes or knowing what behaviours they've done. 369 00:33:25,530 --> 00:33:30,820 And therefore they didn't want to stand on the scales because they didn't want to see what it was going to say. 370 00:33:30,840 --> 00:33:37,950 So that was quite interesting cause it really goes against a lot of the ways in which this observational data has been interpreted to date. 371 00:33:39,330 --> 00:33:44,340 The next theme was about attentive and reactive self-monitoring, which isn't the best wording, 372 00:33:44,340 --> 00:33:46,890 but we couldn't figure out the best way to say this succinctly. 373 00:33:47,220 --> 00:33:51,480 And what this really drew on was that people tended to use self-monitoring in two different ways. 374 00:33:51,780 --> 00:33:57,900 One was just to make sure they were paying attention to what they were doing so as a tool to make sure they were sticking to their goals. 375 00:33:58,140 --> 00:34:02,010 So, for example, as long as you're counting something either calories or grams of fat, it's helpful. 376 00:34:02,220 --> 00:34:05,160 It's that little mind trickery. It keeps it present in the mind. 377 00:34:05,160 --> 00:34:10,140 So if you're keeping a food diary diligently, it's going to make you think about what you eat before you start eating it. 378 00:34:10,350 --> 00:34:17,460 But in that case, self-monitoring was essentially a tool to facilitate adherence to make sure they stuck to whatever their plans were. 379 00:34:18,000 --> 00:34:23,850 On the other end of the spectrum, you had people who were using it as a way to essentially self experiment and analyse 380 00:34:23,850 --> 00:34:27,540 what they were doing and how their behaviours might influence their weight. 381 00:34:27,930 --> 00:34:31,979 So this participants say that all gained a few pounds and so I want to analyse it. 382 00:34:31,980 --> 00:34:39,660 Why did I gain that weight? What has caused this? It became more of a self analysis of why it was successful and how to keep going. 383 00:34:40,740 --> 00:34:43,650 And the third theme was about trust and deception. 384 00:34:43,950 --> 00:34:49,230 So the idea that not all self monitoring is created equal in this way, and also it's not the same for all people. 385 00:34:49,500 --> 00:34:53,640 So some people trusted what the scale said. Some people thought scales were totally unreliable. 386 00:34:53,910 --> 00:34:57,690 Some people were always totally honest in their food diaries. Some people said, Honestly, 387 00:34:57,690 --> 00:35:02,640 food diaries aren't going to work for me because I'm just not going to tell it the things that I eat that I don't want it to know about. 388 00:35:02,670 --> 00:35:08,700 So examples here, one participant saying I have to weigh myself at least every other day, because if I don't, 389 00:35:08,970 --> 00:35:12,600 I can feel that I may be gaining a little weight, but sometimes I can talk myself out of that. 390 00:35:12,600 --> 00:35:20,940 But the scale doesn't lie. On the opposite end here, a participant saying I'd be I feel brave to write it down, but ashamed at the same time. 391 00:35:20,940 --> 00:35:26,160 So just talking about a food diary, I'd probably completed a whole day, but I've conveniently left things out. 392 00:35:26,460 --> 00:35:28,710 So if it isn't written on the paper, you know you've had. 393 00:35:28,800 --> 00:35:32,100 I'm exaggerating, but you've had a cream cake, you know, and you've forgotten to put it down. 394 00:35:32,370 --> 00:35:36,120 And I've conveniently forgotten to do it. You're not being honest with yourself. 395 00:35:36,360 --> 00:35:42,600 So a real range there in terms of self-monitoring, how much you could essentially trust what was coming out of it. 396 00:35:43,860 --> 00:35:46,860 And when we thought through these themes, we also were able, 397 00:35:46,860 --> 00:35:51,450 when we were looking at it from that overall lens and particularly looking at it 398 00:35:51,450 --> 00:35:56,490 through those ideas of the model of good citizenship to link the themes together. 399 00:35:57,930 --> 00:36:02,249 And so what we seemed to find was that people's experiences of self-monitoring, 400 00:36:02,250 --> 00:36:09,840 and especially if they had negative emotional responses relating to shame, very much related to the way in which they were using self-monitoring. 401 00:36:10,170 --> 00:36:14,520 So if they were using that as a way to promote adherence, to stick to their goals, 402 00:36:14,520 --> 00:36:17,820 to make sure they didn't eat the cream cake or to make sure they didn't gain weight, 403 00:36:18,090 --> 00:36:23,580 that was where a lot of negative emotions came out of it because essentially if the self-monitoring didn't result in the change they wanted, 404 00:36:23,910 --> 00:36:31,440 then the self-monitoring had failed as an effort. If they were using it to help them analyse, it gave it more value so you could gain weight. 405 00:36:31,440 --> 00:36:37,379 But that wasn't necessarily a bad end point because you could use that information to then analyse what to do next. 406 00:36:37,380 --> 00:36:43,470 And that idea of self ownership, and especially in the States, the whole idea of personal responsibility for health, 407 00:36:43,470 --> 00:36:48,060 which I am in no way endorsing necessarily plays into this idea of okay, 408 00:36:48,060 --> 00:36:52,620 well yeah, maybe you gained a little bit of weight, but at least you're analysing it and trying to figure out what to do differently. 409 00:36:52,830 --> 00:36:57,540 And that seemed to remove some of that shame and seem to be very much linked to the other themes. 410 00:36:57,540 --> 00:37:02,750 So when we talked about the emotional response to self-monitoring, 411 00:37:02,760 --> 00:37:08,160 participants were more likely to experience shame when they were doing it just to adhere to their goals. 412 00:37:08,640 --> 00:37:13,320 And when they had the self-knowledge and they felt like they were doing it to get to know their bodies better. 413 00:37:13,500 --> 00:37:19,380 This tended to be more on the analysis side of things and similarly trust and deception linked in here. 414 00:37:19,710 --> 00:37:24,540 So people who were doing it to adhere were much more likely to self deceive. 415 00:37:24,780 --> 00:37:29,849 So if they were doing their food diary to make sure they stuck to their food goals and they didn't stick to their food goals, 416 00:37:29,850 --> 00:37:33,480 they were much likely then to just not put that thing in the food diary. Whereas if. 417 00:37:33,510 --> 00:37:36,650 They were doing it to learn more about themselves, to analyse. 418 00:37:36,660 --> 00:37:42,540 There was less of an incentive to deceive in that mindset because essentially they were then corrupting. 419 00:37:42,540 --> 00:37:44,940 They own their own data that they were going to be using. 420 00:37:45,330 --> 00:37:51,100 And certainly it felt like if people trusted the measure that they were using, whether it be the scales or their food diary, 421 00:37:51,120 --> 00:37:57,269 they were much more likely to analyse the information because otherwise you could just say well the scales rubbish and it fluctuates loads. 422 00:37:57,270 --> 00:38:01,290 So who knows if what I'm seeing as a result of my behaviour or something else. 423 00:38:02,850 --> 00:38:05,970 And finally the third review looked at reframing. 424 00:38:06,000 --> 00:38:09,690 So changing the way that people thought or felt about their weight management 425 00:38:09,690 --> 00:38:13,980 attempt in an attempt to facilitate its success or enhance the experience. 426 00:38:14,310 --> 00:38:19,560 And though participants talked about this a lot and it came out through a lot of the qualitative studies we looked at, 427 00:38:19,860 --> 00:38:22,560 we hadn't found any mention of it in the literature before. 428 00:38:22,920 --> 00:38:27,360 And we actually I thought that was so unusual that I was worried I'd missed something and had 429 00:38:27,360 --> 00:38:31,589 quite a few more searches to make sure that I hadn't and I couldn't find it anywhere else. 430 00:38:31,590 --> 00:38:37,620 Surely someone else has picked up on it, but it hasn't been flagged up as a big area and it's something that people seem to be using quite a lot. 431 00:38:37,620 --> 00:38:40,190 And for some people it's quite a positive tool. 432 00:38:40,200 --> 00:38:47,250 So here we were looking at how people use this tool and if it provided benefits or harms used within self-directed weight loss. 433 00:38:48,270 --> 00:38:52,680 So we updated the searches for this and ended up with 23 studies. 434 00:38:52,950 --> 00:38:57,720 We use thematic synthesis again, just because it was what I was familiar with and it worked so far. 435 00:38:58,860 --> 00:39:07,290 And here we again used an inductive approach to just coding whatever we found at the first and second stage, and then for the third stage, 436 00:39:07,290 --> 00:39:11,040 try to look at where this might Lincoln with the concept of cognitive restructuring, 437 00:39:11,040 --> 00:39:16,770 which is something that is used in CBT to help people deal with maladaptive thoughts. 438 00:39:18,450 --> 00:39:23,429 And we identified three themes here. This was much more of a descriptive review in the end, actually, 439 00:39:23,430 --> 00:39:26,490 so you kind of don't know what you're going to end up with until you start coding things. 440 00:39:26,730 --> 00:39:31,350 And with self-monitoring, it felt like there was a lot of internal linkages between themes here. 441 00:39:31,350 --> 00:39:35,580 We didn't find so many into linkages, but it was still very interesting to look at what people were saying. 442 00:39:36,000 --> 00:39:40,350 So one of the probably the most common thing that came across was reframing eating disorder, 443 00:39:40,350 --> 00:39:44,250 eating behaviours and specifically moving away from the word diet. 444 00:39:44,550 --> 00:39:47,970 And this was particularly the case in people who had been on many, many diets, 445 00:39:48,270 --> 00:39:51,419 felt they had failed in the past, had very negative connotations with that, 446 00:39:51,420 --> 00:40:00,510 and couldn't face the idea of going on another diet, but essentially did it in the ways that us as researchers might think of going on a diet. 447 00:40:00,510 --> 00:40:03,959 So they were restricting their calorie intake, but they were calling it something else. 448 00:40:03,960 --> 00:40:08,670 And typically it was just reframing it to calling it a way of life or a lifestyle change. 449 00:40:09,180 --> 00:40:12,930 So an example here, I think you've got to tell yourself you're not on a diet, 450 00:40:12,930 --> 00:40:16,950 you're changing your way of life, you're not on a diet, which is a temporary thing. 451 00:40:17,340 --> 00:40:21,270 And the idea was you can go on diets, then you just stop going on them and you regain the weight. 452 00:40:21,270 --> 00:40:27,060 Whereas if you conceptualise it as something different, something that's not just the way you live your life, people found that helpful. 453 00:40:28,260 --> 00:40:35,220 And another thing people were doing was reframing food. So actually using quite a few metaphors around food and what they thought of it. 454 00:40:35,470 --> 00:40:38,550 Some people spoke of it as a toxin or as a drug. 455 00:40:38,820 --> 00:40:42,660 This person thought of it as fuel. So they said, I have to think of food differently. 456 00:40:42,870 --> 00:40:48,210 I don't want to celebrate it, you know, I just think it's fuel. Like I don't celebrate putting gas in my car. 457 00:40:49,530 --> 00:40:54,599 The next group was around reframing behavioural goals and this was very similar to reframing 458 00:40:54,600 --> 00:40:59,580 eating behaviours and that it was mainly people who had experience trying to lose weight before, 459 00:40:59,880 --> 00:41:06,780 had negative experiences with that, felt like they wanted to embark on another attempt to lose weight to improve their health, 460 00:41:06,780 --> 00:41:10,440 but just essentially needed some different language to facilitate that. 461 00:41:10,980 --> 00:41:14,070 So one person said, let's not focus on weight loss. 462 00:41:14,070 --> 00:41:20,820 Let's focus on health and lifestyle. It has to be about empowering bigger people to make choices that will benefit their lifestyle in their life. 463 00:41:21,060 --> 00:41:26,940 It shouldn't be about weight loss. Let's take it away from the kilos and the pounds and you've got to lose, lose, lose. 464 00:41:27,120 --> 00:41:33,269 And again, this was a participant who had a history of repeatedly going on weight loss diets and getting 465 00:41:33,270 --> 00:41:36,899 more and more negative emotions around that and found reframing it to something else, 466 00:41:36,900 --> 00:41:40,740 a very helpful way to help them achieve those healthier goals. 467 00:41:41,520 --> 00:41:46,229 And finally, some people actually didn't reframe the diet, didn't necessarily reframe the goals, 468 00:41:46,230 --> 00:41:50,040 but actually said, I'm just going to think of myself as a different person. I'm reframing my own identity. 469 00:41:51,030 --> 00:41:56,280 And an example here is of someone who stated I decided I was going to become a runner. 470 00:41:56,490 --> 00:41:58,229 And then when I changed my mindset about that, 471 00:41:58,230 --> 00:42:02,400 that I eat healthily because I'm a runner and if I don't eat healthy, then I'm not going to run as well. 472 00:42:02,640 --> 00:42:07,260 It makes it seem less like something I'm forcing myself to do than something that I enjoy doing. 473 00:42:07,290 --> 00:42:14,790 So all of this came from negative experiences with previous weight loss attempts and trying to frame it for themselves as something more positive. 474 00:42:14,790 --> 00:42:16,770 So this is people essentially with no prompting, 475 00:42:17,010 --> 00:42:27,210 using a form of cognitive restructuring on themselves to make their next attempt at healthier eating and exercise in more a more bearable attempt. 476 00:42:29,070 --> 00:42:33,270 So all systematic reviews should hopefully end with recommendations. 477 00:42:33,380 --> 00:42:37,340 For research and recommendations for practice. You've gone you've read all the literature in an area. 478 00:42:37,580 --> 00:42:41,300 You definitely want to take a look at those. And so that's what I'm going to finish up with today. 479 00:42:41,720 --> 00:42:47,209 With Review one, we came out with very specific recommendations to basically say, Please, 480 00:42:47,210 --> 00:42:50,960 if we do this review again, can we find some better studies that don't have these issues? 481 00:42:51,800 --> 00:42:55,010 So we wanted people to make their protocols available so we could tell what they 482 00:42:55,010 --> 00:43:00,139 actually did in their analyses to use different methods for recruitment to please, 483 00:43:00,140 --> 00:43:03,200 please talk about the relationship between the researcher and participant. 484 00:43:03,500 --> 00:43:05,600 For those of you who might be doing a qualitative study, 485 00:43:05,600 --> 00:43:10,010 I'm sure you will because you've heard from memory, but some people haven't had the benefit of that. 486 00:43:10,310 --> 00:43:16,190 And to be explicit about your data analysis process from review to we found 487 00:43:16,190 --> 00:43:19,879 that there wasn't a one size fits all approach to self monitoring and studies. 488 00:43:19,880 --> 00:43:24,350 There are lots and lots of studies those conducted within our team that asked participants to self monitor. 489 00:43:24,350 --> 00:43:30,200 We said they might want to think about offering participants a choice of tools and also that future research might 490 00:43:30,200 --> 00:43:35,029 want to draw it more explicitly the thoughts that people have and the emotions generated by self monitoring. 491 00:43:35,030 --> 00:43:40,429 So though lots of our studies talked about self monitoring, very few of them set out to look at that. 492 00:43:40,430 --> 00:43:43,400 Very few of them were actually trying to understand the emotions people had. 493 00:43:43,610 --> 00:43:48,679 It was that it was such an emotive experience for participants that they were bringing it up in the context of other questions. 494 00:43:48,680 --> 00:43:52,700 So we thought here more research looking at that specifically might be useful. 495 00:43:53,480 --> 00:43:54,860 And finally, for reframing, 496 00:43:54,860 --> 00:44:00,589 we found it certainly seemed an important technique for some people and there didn't seem to be any academic literature on it. 497 00:44:00,590 --> 00:44:08,629 So we thought we might benefit from understanding more about it as a technique and where it may be similar to and where it may be different from. 498 00:44:08,630 --> 00:44:12,980 Cognitive restructuring and for recommendations for practice, 499 00:44:12,980 --> 00:44:17,810 we found that people used a really wide range of strategies in self-directed weight loss 500 00:44:18,920 --> 00:44:22,909 and it might be that studies want to encourage people to use more than one strategy, 501 00:44:22,910 --> 00:44:28,760 try them out, see how they work for them. There might not really be a one size fits all approach here. 502 00:44:30,680 --> 00:44:37,969 Self-monitoring, we definitely and I kind of felt strongly coming out of this review that we should look into framing self-monitoring really as 503 00:44:37,970 --> 00:44:45,030 a tool to aid analysis to help hopefully mitigate the phenomenon of shame that was leading to abandonment of self-monitoring. 504 00:44:45,060 --> 00:44:52,700 This is something that seemed to be a really useful way for people to get away from the shame that they were experiencing. 505 00:44:53,270 --> 00:44:58,909 And we thought basically interventions could benefit from explicitly encouraging their participants to do this. 506 00:44:58,910 --> 00:45:04,850 You know, if you don't say anything either way, definitely some people are going to interpret it as a tool to monitor their adherence, 507 00:45:05,060 --> 00:45:10,040 and that may well lead to the experiences of shame, which then lead to them abandoning their attempt. 508 00:45:10,370 --> 00:45:16,699 And I think also what this pointed out to us was those we are not operating in a bubble and we cannot roll 509 00:45:16,700 --> 00:45:22,939 out these interventions without thinking about the broader context of societal discourses around obesity, 510 00:45:22,940 --> 00:45:26,300 around self-knowledge, around health, around personal responsibility. 511 00:45:27,380 --> 00:45:32,150 And finally, with the third review, looking at reframing, 512 00:45:32,390 --> 00:45:37,549 we thought that weight loss interventions could benefit from thinking about ways that they describe their interventions. 513 00:45:37,550 --> 00:45:45,740 So if loads of people are finding the word diet unhelpful, why not try possibly using a different word, or at least saying to someone, 514 00:45:45,740 --> 00:45:51,709 it might be helpful for you to think about this as changing your way of life instead of conceptualising this as a diet. 515 00:45:51,710 --> 00:45:55,880 And we found that programs might be able to benefit their users if they aid them to change 516 00:45:55,880 --> 00:46:00,020 the language and the metaphors that they use and particularly reflect on past experiences. 517 00:46:00,020 --> 00:46:05,479 So for the vast majority of people trying to lose weight, this is not the first time in their life that they have tried to lose weight. 518 00:46:05,480 --> 00:46:11,750 They have tried to lose weight many times, and they will bring with them all of the experiences that they've had from those previous attempts. 519 00:46:11,750 --> 00:46:17,690 And learning from those and reflecting on those instead of essentially ignoring them might be a good way to move forward. 520 00:46:17,990 --> 00:46:24,680 So in conclusion, definitely worth it to do qualitative, systematic reviews here because we identified new strategies that we wouldn't 521 00:46:24,680 --> 00:46:28,520 have found if we just looked at the academic literature of intervention reports. 522 00:46:29,360 --> 00:46:31,909 The Maddocks synthesis, I thought was a very, very useful tool. 523 00:46:31,910 --> 00:46:37,760 And for people who haven't done qualitative syntheses before, I found it quite intuitive and easy to follow approach, 524 00:46:37,760 --> 00:46:43,340 whereas I think some of the other ones might be a bit more daunting and it definitely facilitated rich comparisons. 525 00:46:44,270 --> 00:46:49,520 And finally, the reality was our ability to draw firm conclusions and if you read the limitation sections 526 00:46:49,520 --> 00:46:54,020 of all these three papers was limited by the quality of the studies that we included. 527 00:46:54,020 --> 00:46:58,759 And particularly, it was difficult to determine if what we were reporting really reflected the experiences 528 00:46:58,760 --> 00:47:04,010 of the participants or if it was reflecting the researchers own take on the situation. 529 00:47:04,520 --> 00:47:07,880 So very happy to take questions. That's a picture of my son looking very quizzical. 530 00:47:08,090 --> 00:47:12,650 I'd like to put him up there because I had him whilst I was doing my PhD and doing this research. 531 00:47:13,550 --> 00:47:15,070 Great. Thank you.