Hi, everyone. Thank you for coming tonight.
So as Emory said, I'm Jamie Horton, voice senior researcher in Health Behaviours at the Department of Primary Care.
And I spend the vast majority of my working life doing systematic reviews.
And so today I'm here to talk to you about findings from three qualitative,
systematic reviews we conducted looking at adults experiences of trying to lose weight on their own.
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,
which was helped by lots of people, including the lovely Anne Murray.
And this work was supported by the National Institute for Health Research, which is essentially the research arm of the NHS.
So I don't have any conflicts of interest to declare in that regard.
So what I'll talk about today a very quick introduction to what we mean when we talk about qualitative
synthesis and then some background into the research that I'll be going into on the self management of weight.
I'll talk you through the aims and the methods of the three reviews, their key findings and their implications.
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,
some because you're possibly more interested in the qualitative methodology.
I'll try to cover both of those and mainly through work examples of the reviews.
So what we really mean by qualitative, systematic reviews are syntheses is the process of pooling qualitative and mixed method research
data and then drawing the conclusions regarding the collective meaning of that research.
So what I started off in systematic reviews, I was very much on the quantitative side of things,
so I was looking at mainly randomised controlled trials, their effect measures, and then pooling those using statistical methods.
Qualitative, systematic reviews are a very different story and I'd say in recent years they're becoming more and more frequent.
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?
And they wanted us to look at lifestyle weight management programs for overweight and obese adults.
And so that means things like Weight Watchers or Slimming World and whether or not GP should refer patients to these.
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.
But then they were also very interested in the barriers and facilitators to these programs.
So there's no point in doctors having this as their suite of things to offer if the
doctors aren't going to offer them or if the patients aren't going to take them up.
And that's when we did a qualitative,
systematic review to look at people's experiences in attending or not attending these programs and doctor's experiences as well.
So qualitative,
systematic reviews have really for me come from that place of trying to understand people's experiences with health care interventions.
And sometimes that means they're pairing up with quantitative, systematic reviews, and sometimes they stand on their own.
Now there are a few steps to conducting a qualitative synthesis.
The first few on this are very similar whether or not it's a qualitative or quantitative systematic review.
So with a systematic review, we go out, we come up with a research question.
In our field, it's usually about a health care intervention.
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.
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,
and this is really to make sure partly that we're all on the same page in terms of moving forwards,
but also to make sure we are trying to reduce bias and be as transparent as possible.
Because the idea of a systematic review is kind of the keys in the word systematic.
It should be transparent, it should be reproducible. So we should be able to publish our protocol.
And if someone wanted to go and copy it, they should be able to do that.
We then conduct searches, so we search numerous databases and also some other types of literature, which I'll talk about in a bit.
For relevant studies, we screen them down for the ones that are actually relevant to that research question we're trying to answer.
And then we go and we extract the data, the information that we want from those studies.
So up to there, exactly the same. If it's a quantitative or qualitative systematic review, at the bottom, things get a bit different.
And that's the part where we bring all of our findings together and then of course, write it up.
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.
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.
But it is also worth acknowledging that thematic synthesis is not the only way to do a qualitative synthesis.
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.
They identified these nine unique methods. For the sake of all of us, I'm.
Going to go through each of those today. But if you are interested in learning more about them,
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.
And they also link to some examples of each of those.
But as I said, for us, we used thematic synthesis and I'll go into the reasons behind that in a bit.
So moving on from that, as I mentioned this, these reviews came out of my Dphil research and my Dphil research was specifically
interested in looking at self-directed weight loss in adults with overweight or obesity.
So there are a few reasons why I picked this as the area I was interested in.
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.
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
vast majority of them are doing this without any sort of professional support or support from a formal programme.
So rather than losing weight with help from their GP or their practice nurse or through going to Weight Watchers,
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.
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.
Now, paradoxically, even though the vast majority of these people who are trying to lose weight are doing it in self-directed means,
if you look at the research, the focus of the research is very much on weight loss efforts that involve some sort
of professional support or support from an intervention such as Weight Watchers.
There are a number of reasons for this imbalance.
Partly it's just easier to study people if they are part of an intervention because they're showing up to it.
You can track them much easier. It's much easier to identify them.
Also, of course, there's more impetus, for example,
from the health care sector to study interventions delivered by doctors from the commercial sector to study commercial programs.
And so this group of people who are trying to lose weight on their own were really pretty much under-researched.
And when we did our systematic reviews on behalf of Nice and we looked at all these formal weight loss interventions,
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.
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.
And the reason this came out is kind of the big research aim is the lack of research in this area generally.
So what I was interested in doing through my Ph.D. was trying to figure out, okay,
what strategies that people are using seem to be associated with success, seem to be helpful, which strategies are not helpful?
But it was impossible to do that without actually first having a list of the strategies that people were using.
And I just wanted to quickly give a shout out to this picture here.
And the image credit here is that it's from the World Obesity Society Image Bank.
So working in this field for quite a few years now,
you often see presentations with pictures of adults living with overweight or obesity that are quite stigmatising.
That is definitely what we tend to see in the media a lot.
And the World Obesity Society Image Bank is a collection of free to use open copyright images that are hopefully not stigmatising.
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?
That was the first step of my PhD. It was to develop something that we called the Oxford Food and Activity Behaviours taxonomy,
and that was basically generating a list of all the strategies that it seemed like people might use to control their weight.
And we did this by using a grounded framework approach, looking at commonly used weight loss resources,
coding them, so picking out all the strategies from them.
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,
taxonomies and theories, consulting with colleagues who are primarily academics.
And we ended up with this list of 117 strategies grouped into 21 domains.
So just a few examples of those to get a sense of what I mean.
So for example, goal setting was a domain that involves setting goals in terms of how much weight
you wanted to lose each week or how many calories you're going to eat each day,
or how many steps you were going to take. So all kind of things that weren't necessarily surprising,
but being able to categorise all of them and then link them into broader descriptive themes.
Now those steps all yielded all these strategies,
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.
Whether or not those be interventions or kind of academic thinking on weight loss.
And what we're really interested in is what people were doing outside of academia, outside of these formal interventions.
So we wanted to make sure that we looked at this from another angle.
We couldn't really do a quantitative survey of this because we didn't know which strategies.
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.
But it felt like something that just interviewing 20 people, you're probably still not going to get a full range of strategies.
So we thought actually,
let's start out with a review of the qualitative literature to see what's come out in a range of different qualitative studies.
And that brings me on to the first of these qualitative syntheses that I'm going to be discussing today.
So in my Ph.D., I said, okay, this is great.
One of the chapters of this Ph.D. is going to be a qualitative, systematic review to check if I'm missing any strategies.
So the questions that asked were what cognitive and behavioural strategies do people report using in self-directed weight loss attempts?
What language do they use to describe these strategies?
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,
we were using language that made sense to people and also some questions around the barriers and facilitators to implementing these strategies.
So for example, something like self-monitoring, if people are using it, what are they finding useful about it?
What are they finding not useful about it? What should we bear in mind in the future?
Because of course you have your individual strategies, but they can all be implemented in very different ways.
Now, we weren't expecting that many studies to come up, and so this is what I'd set out three very simple questions,
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.
So journal articles very,
very limited on their space and there was actually quite a lot of rich data and more studies than we were originally expecting.
So we ended up doing some more synthesis on the back of this work and those looked at specific groups of strategies.
And I'll talk about those as well.
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,
reflected such a variation of experiences.
And a lot of those experiences were very negative. So we felt like that really deserved some attention.
And the other, which I will come on to, was reframing, and that's a new strategy that emerged as part of this review.
So that hadn't come through in any of the intervention materials we'd looked at in any of the academic literature.
But actually when we read participant accounts of what they were doing, this was a cognitive strategy that they were employing.
So when we go back to thinking about our different steps of conducting a qualitative, systematic review right at the beginning,
when we think about generating our research question and definitely when we're putting together a protocol, we think about our inclusion criteria.
If you're doing a quantitative, systematic review, you typically use a framework called PICO.
If you're doing a qualitative, systematic review, the most common framework to use is spice.
And this is really important because this helps you narrow down what studies you will include to make
sure that they're all similar enough that they're actually going to be a useful thing to synthesise.
And so we were interested in studies conducted in community, in primary care,
in adults who had attempted or were attempting to lose weight through behaviour change.
And our specific interest was the strategies that they were using in their self-directed efforts to lose weight.
And so what we were definitely not interested in were program evaluations and we sifted through loads and loads and loads of those.
So a lot of the randomised controlled trials in this area and a lot of the commercial interventions have
a qualitative study alongside them that ask about people's experience of that particular intervention.
That wasn't what we were interested in. We were interested in people who had not experienced any of these interventions
and they were talking about what they did essentially off of their own back.
We didn't restrict studies in terms of comparisons and in terms of our evaluations.
We included only qualitative studies. So that means we didn't include kind of large surveys or anything like that.
Mainly what we were looking at were studies which primarily used 1 to 1 interviews
or focus groups to elicit patient experiences and participant experiences.
So searching for qualitative literature, for any of you thinking of doing a qualitative,
systematic review, this is one of the tricky and sticking points.
When we're searching for randomised controlled trials in large databases,
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.
And there you go. Qualitative literature is not the same.
This is partly because we are looking at such a wide range of methods and also
because people use such different language to describe the same methods.
So we did our database searches, but we also did a few other things to try and capture more studies that might be relevant.
And so one of the things that we know is that studies tend to cite other studies that are like them.
So we did a lot of forward and backward citation screening, which basically means using something like Google Scholar or Web of science,
plugging in the article that we knew was relevant to us and looking at all the
studies that had cited that article and all the studies that that article cited,
and just kind of going through that. Way to. To see if we were missing anything.
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,
we also search through dissertations and a lot of people's PhDs involved qualitative analysis.
And actually the pages ended up being probably the richest source of data we had because they had tended
to have these extensive appendices where they just have the whole transcripts of their interviews,
which certainly isn't something you'd find in a published journal article.
So that was quite different from doing a quantitative review as well.
With systematic reviews.
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.
This is a pretty boring thing and it's a lot of numbers I won't go through in detail.
But basically from starting out with around 3000 references,
we ended up with 31 included studies which represented just over a thousand participants across those 31 studies.
In terms of data extraction. So this is where we've done our screening.
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.
This was done independently by two people, mainly by me and Anne Marie.
And the reason behind that is that we all see different things in different studies.
So if you just have one person do it, that's totally fine if that's all you can manage.
But certainly we found places where she'd pick up something that I hadn't picked up,
and particularly because this is somewhat subjective when it comes to saying, is that a self-management strategy or not?
It was really useful to have two of us looking at it.
So we extracted our self-management strategies, the general characteristics of the studies and also quality assessment.
And I will talk through that in more detail too. So quality assessment.
All systematic reviews should be using some sort of established tool to look at whether or not the studies they are including are rubbish.
So a key part of a systematic review is not just saying, okay, this, studies found this and all together this suggests this,
but it's trying to look at each individual study and say, How much do I actually trust what these people are telling me?
The more you do systematic reviews, the less trusting, unfortunately you get of the scientific literature.
And here I'd say that was no exception. The more studies you read and the more times you use these critical appraisal
tools which really get you in the mindset of where there might be weaknesses,
unfortunately, the more weaknesses you find. So we used a tool developed by the Joanna Briggs Institute to look at qualitative literature.
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.
And it was certainly something that we paid a lot of attention to in the limitations section of our own papers.
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,
it might be useful to see an example of the type of questions we're asking for each of these studies.
So we wanted to see a clear statement in terms of the aims of the research.
We wanted to see that qualitative methods were appropriate, that the research design was appropriate,
that the recruitment strategy was appropriate to the aims of this research.
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.
And then how did they go out and actually identify these people?
This was a place where a lot of our studies fell down.
They just didn't recruit people in a way that actually suited their aims.
So in this example, we said, no,
this study didn't use an appropriate recruitment strategy because their original question was about weight loss in men,
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.
And then they didn't involve the men who underwent screening there. So yeah, not not a great story in terms of their recruitment.
I won't name and shame them. Was the data collected in a way that was sensible?
Another really key point that some of you will have been learning about in your course is
the relationship in qualitative research between the researcher and the participants,
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.
So this is acknowledging that the person who is interviewing in most cases in these studies, they their own views,
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.
And so you want to see in qualitative studies that people are doing that.
Unfortunately, it doesn't happen all that often. You want them to take into account.
Ethical considerations, at a minimum have gone through an ethics board,
but also to get some sense that they didn't just treat it as a tick box exercise.
This is a sensitive issue and you want it to feel like people have actually thought that through.
Next point where a lot of studies fell down was on data analysis and whether or not it was sufficiently rigorous.
Most of the time it was just impossible to tell because no one really told us what they did.
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.
Somehow they got to their results and these themes and we just didn't know what
happened in between those two points if more than one person was involved.
And a real issue here, too, was if people didn't report any quotes.
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.
And that made you think sometimes, is this really what they found or is it just what the researcher hoped they'd found?
And so they wrote it. And I actually don't know if I trust what they found or not.
A lot of times researchers are doing things for very, very good reasons.
Sometimes they're doing them for not so good reasons, like to inform a funding application.
And so if you're not seeing quotes, you're seeing statements, you don't know how they match up.
It's just difficult to evaluate how much that's a reflection of the participants actual experiences.
And finally, what's the research value? But we did say yes for every single study for that.
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.
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.
And then if a study had something that fell into that,
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.
So for example, here for Budding, which was about basically performing your target behaviours with another person,
we extracted the text from this study of a participant stating If I'm committed to somebody else, I will do it.
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.
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.
And the other thing that we were definitely looking for here were strategies that didn't fall within our pre-established list.
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.
And we did that based on the principles of thematic synthesis.
So I'm going to go into that in a bit more detail.
Thematic synthesis, for those of you who are familiar with thematic analysis, is very, very similar.
It's basically just extending thematic analysis to use it in systematic reviews.
What that means practically is that the first thing you do is you go through and you line by line code.
You can do this in In-vivo, which is specialist software for qualitative research.
You can do it the old fashioned way, which I do,
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.
I originally was an English literature major, and I cannot escape that mode of thinking.
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.
So, for example, if I was doing this on self management strategies, I might have style, underline software and underline food,
diary, etc. and that might all sit under a descriptive theme of self-monitor and more generally.
And then you go on to probably the most interesting part, which is interpreting your third order theme.
So you're looking at these descriptive themes that the content in them and thinking how they linked together, where they might sit.
And this is where the real kind of I'd say creativity comes into some regard before that you're doing more descriptive and
here you're actually trying to build on what you've found and turn it into something more meaningful than just a summary.
And that really coincided nicely for us. And the reason we chose it was because it coincided nicely with building the taxonomy.
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
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.
So in terms of our included studies, 30 odd of them sampling methods weren't great.
11 of the studies didn't specify. Six of them is convenient sampling.
And often this meant they just didn't recruit the number of participants they needed or the type of participants they needed.
And in terms of the method of data collection, the majority of them. So 20 of the studies were using individual interviews.
We also had some using focus groups, some using a combination and two studies which were quite interesting studies,
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.
Quality assessment wasn't great and Murray and I were quite harsh on most of these studies.
The majority stated their aims and using appropriate design presented valuable information.
However, as I said before, recruitment was a real issue for a lot of these,
as was demonstrating that they'd considered the relationship between the
researcher and the participants and reporting a rigorous method of data analysis.
And approximately half demonstrated that they'd looked at ethical issues and provided a clear statement of findings.
So that's not a great picture of that overall research in this field.
And that definitely limited what we were able to say,
because you can only be as confident in your findings as you are in the studies that you're taking those findings from.
So we mapped the number of studies coded against each domain. I'm not expecting you to look at this other than in detail,
other than to say all of the domains that we've come up with in our original categorisation were covered.
The most commonly used one was restrictions. But this was a lot of information.
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.
So what this looked like was for regulations, restriction statements such as people experience negative attitudes,
feelings of deprivation, which were presented as challenges to maintain and use of those strategies and things about falling off the web.
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.
We can't do anything with them. Which is why we went on.
Did the subsequent analysis only thing that people generally felt quite positive about for the rest of these,
they either felt mixed or actually that having had predominantly negative experiences was scheduling
people really when they were talking about strategies that had to do with scheduling quite positive.
So viewed as a way in which to establish a route sustainable routine with one participant explaining,
You just got to get into that schedule and it's automatic and it really makes it easier when you do have a routine.
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.
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.
The first of those was reframing and we actually did a subsequent review of that, which we'll talk about.
And reframing is the concept of people changing the language or the way they think about a weight loss
attempt or the behaviours that go into that weight loss attempt in order to either enhance their success,
to make it less of a negative experience or to make it easier to maintain.
And I will get on to examples of that shortly.
And the other was self experimentation and that was people basically actively doing essentially experiments on themselves,
saying this week, I'm cutting out carbohydrates, I'm going to see what happens to my weight.
If it doesn't work, I'll do something else. If it does work, maybe I'll stick with it.
So using themselves as a science experiment.
So key findings from Review one were that the most commonly covered types of strategies are
the ones we have to be careful or we can't say the ones that participants most commonly used.
We can say the ones that researchers most commonly reported on were restrictions,
self-monitoring, scheduling, professional support and weight management AIDS.
And with the exception of scheduling, as I mentioned, most people had mixed or negative feelings about implementation of these strategies.
And also interestingly, from looking at all of these,
we found that there was a variation in the strategies that people used based on the point they were in their weight management attempt.
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.
They were focusing on only one or two strategies and then when they were getting into the ends of those attempts or thinking, okay,
now I just want to try and keep the weight off,
they were starting to get more and more strategies that they were using as part of their everyday life.
So a definite shift and something we saw in more than one study in that regard.
And as I said, two new groups of strategies were added.
So going on to review to and why we decided to look specifically at self-monitoring in more detail.
Self-monitoring is pretty ubiquitous in weight loss attempts, and it's certainly ubiquitous in weight loss interventions.
So there are very few weight loss interventions that won't tell you to weigh yourself and to record what you eat.
And a lot of them will tell you to record your physical activity as well.
And when you look at the observational data,
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.
And so than people think, Oh, that's great.
We can just tell people to weigh themselves more and it'll work and everyone will lose weight and keep it off.
And that absolutely isn't the case.
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.
So that was one of the reasons we wanted to look into this.
But also a lot of the studies that had looked at self monitoring from a qualitative angle had done so.
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.
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.
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.
So the questions we're asking here is what forms of self monitoring are used within weight management attempts?
What are the roles of self undoing within those attempts? And we were also interested in the mechanisms through which self monitoring works.
So in some cases it does seem to work, it seems to facilitate weight loss, in others it doesn't.
And what are the differences? What are the things influencing those mechanisms?
So methods here we focus just on those studies from review one that talked about self
monitoring and that was a group of 22 studies and we used an interpretive approach,
which means and I'm going to have to read it verbatim because otherwise I say interpretation too many times,
reinterpreting interpretations to interpret courage, development of new insights and concepts.
So this is looking at not only the participant quotes, but also the ways in which they'd been interpreted by the authors.
And so again, here we used thematic synthesis,
so we identified and coded first order themes and synthesise our second order themes through an inductive approach.
So we just said, let's see what's in the data without trying to put any of our already known thoughts on it.
I'm sure we still did absolutely do that. And then we interpreted third order themes with some help through.
So there we go. Inductive and third order themes helped through thinking about existing theories.
And there are two things that we drew on here. One was a psychological theory of self regulation.
This is often posited to be the thing that makes self-monitoring work,
and it's basically about a feedback loop where you get this information, you use it to then regulate your behaviour.
So that's a very simplified version of it. And the other which I was interested in,
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,
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
his model of good citizenship and essentially morality and science and how that all pulls together,
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.
So three main themes came out of these reviews and these are those third order themes.
So when we actually put our thinking caps on and thought about, okay, we've seen what it describes, but what does it mean?
The first of those was self-perception and emotions.
So this was the idea that participants felt that self-monitoring was really helping them get to know themselves,
and this tended to be quite an emotional process.
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.
And she was talking about that within the context of weighing herself and trying to figure out what was going on.
However, this also linked to some very hard things for people.
So one woman stated, Recording my food intake is the hardest thing.
Maybe it's the ultimate ownership of what I'm doing.
And another participant stated, When genes don't fit, you're scared to get on.
I used to weigh myself. I don't anymore.
And one of the things from the observational literature that you look at is if you look at people losing weight,
when they start to stop losing weight, they also start to stop weighing themselves.
And a lot of times this is interpreted in the academic literature as meaning it must be weighing themselves that made them lose weight.
And so they've stopped weighing themselves. So this is why they're gaining weight.
The data in this study, as you might expect, actually shows something very different, which is that people know themselves.
They knew they were starting to gain weight, whether it be through the fit of their genes or knowing what behaviours they've done.
And therefore they didn't want to stand on the scales because they didn't want to see what it was going to say.
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.
The next theme was about attentive and reactive self-monitoring, which isn't the best wording,
but we couldn't figure out the best way to say this succinctly.
And what this really drew on was that people tended to use self-monitoring in two different ways.
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.
So, for example, as long as you're counting something either calories or grams of fat, it's helpful.
It's that little mind trickery. It keeps it present in the mind.
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.
But in that case, self-monitoring was essentially a tool to facilitate adherence to make sure they stuck to whatever their plans were.
On the other end of the spectrum, you had people who were using it as a way to essentially self experiment and analyse
what they were doing and how their behaviours might influence their weight.
So this participants say that all gained a few pounds and so I want to analyse it.
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.
And the third theme was about trust and deception.
So the idea that not all self monitoring is created equal in this way, and also it's not the same for all people.
So some people trusted what the scale said. Some people thought scales were totally unreliable.
Some people were always totally honest in their food diaries. Some people said, Honestly,
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.
So examples here, one participant saying I have to weigh myself at least every other day, because if I don't,
I can feel that I may be gaining a little weight, but sometimes I can talk myself out of that.
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.
So just talking about a food diary, I'd probably completed a whole day, but I've conveniently left things out.
So if it isn't written on the paper, you know you've had.
I'm exaggerating, but you've had a cream cake, you know, and you've forgotten to put it down.
And I've conveniently forgotten to do it. You're not being honest with yourself.
So a real range there in terms of self-monitoring, how much you could essentially trust what was coming out of it.
And when we thought through these themes, we also were able,
when we were looking at it from that overall lens and particularly looking at it
through those ideas of the model of good citizenship to link the themes together.
And so what we seemed to find was that people's experiences of self-monitoring,
and especially if they had negative emotional responses relating to shame, very much related to the way in which they were using self-monitoring.
So if they were using that as a way to promote adherence, to stick to their goals,
to make sure they didn't eat the cream cake or to make sure they didn't gain weight,
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,
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.
But that wasn't necessarily a bad end point because you could use that information to then analyse what to do next.
And that idea of self ownership, and especially in the States, the whole idea of personal responsibility for health,
which I am in no way endorsing necessarily plays into this idea of okay,
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.
And that seemed to remove some of that shame and seem to be very much linked to the other themes.
So when we talked about the emotional response to self-monitoring,
participants were more likely to experience shame when they were doing it just to adhere to their goals.
And when they had the self-knowledge and they felt like they were doing it to get to know their bodies better.
This tended to be more on the analysis side of things and similarly trust and deception linked in here.
So people who were doing it to adhere were much more likely to self deceive.
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,
they were much likely then to just not put that thing in the food diary. Whereas if.
They were doing it to learn more about themselves, to analyse.
There was less of an incentive to deceive in that mindset because essentially they were then corrupting.
They own their own data that they were going to be using.
And certainly it felt like if people trusted the measure that they were using, whether it be the scales or their food diary,
they were much more likely to analyse the information because otherwise you could just say well the scales rubbish and it fluctuates loads.
So who knows if what I'm seeing as a result of my behaviour or something else.
And finally the third review looked at reframing.
So changing the way that people thought or felt about their weight management
attempt in an attempt to facilitate its success or enhance the experience.
And though participants talked about this a lot and it came out through a lot of the qualitative studies we looked at,
we hadn't found any mention of it in the literature before.
And we actually I thought that was so unusual that I was worried I'd missed something and had
quite a few more searches to make sure that I hadn't and I couldn't find it anywhere else.
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.
And for some people it's quite a positive tool.
So here we were looking at how people use this tool and if it provided benefits or harms used within self-directed weight loss.
So we updated the searches for this and ended up with 23 studies.
We use thematic synthesis again, just because it was what I was familiar with and it worked so far.
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,
try to look at where this might Lincoln with the concept of cognitive restructuring,
which is something that is used in CBT to help people deal with maladaptive thoughts.
And we identified three themes here. This was much more of a descriptive review in the end, actually,
so you kind of don't know what you're going to end up with until you start coding things.
And with self-monitoring, it felt like there was a lot of internal linkages between themes here.
We didn't find so many into linkages, but it was still very interesting to look at what people were saying.
So one of the probably the most common thing that came across was reframing eating disorder,
eating behaviours and specifically moving away from the word diet.
And this was particularly the case in people who had been on many, many diets,
felt they had failed in the past, had very negative connotations with that,
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.
So they were restricting their calorie intake, but they were calling it something else.
And typically it was just reframing it to calling it a way of life or a lifestyle change.
So an example here, I think you've got to tell yourself you're not on a diet,
you're changing your way of life, you're not on a diet, which is a temporary thing.
And the idea was you can go on diets, then you just stop going on them and you regain the weight.
Whereas if you conceptualise it as something different, something that's not just the way you live your life, people found that helpful.
And another thing people were doing was reframing food. So actually using quite a few metaphors around food and what they thought of it.
Some people spoke of it as a toxin or as a drug.
This person thought of it as fuel. So they said, I have to think of food differently.
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.
The next group was around reframing behavioural goals and this was very similar to reframing
eating behaviours and that it was mainly people who had experience trying to lose weight before,
had negative experiences with that, felt like they wanted to embark on another attempt to lose weight to improve their health,
but just essentially needed some different language to facilitate that.
So one person said, let's not focus on weight loss.
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.
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.
And again, this was a participant who had a history of repeatedly going on weight loss diets and getting
more and more negative emotions around that and found reframing it to something else,
a very helpful way to help them achieve those healthier goals.
And finally, some people actually didn't reframe the diet, didn't necessarily reframe the goals,
but actually said, I'm just going to think of myself as a different person. I'm reframing my own identity.
And an example here is of someone who stated I decided I was going to become a runner.
And then when I changed my mindset about that,
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.
It makes it seem less like something I'm forcing myself to do than something that I enjoy doing.
So all of this came from negative experiences with previous weight loss attempts and trying to frame it for themselves as something more positive.
So this is people essentially with no prompting,
using a form of cognitive restructuring on themselves to make their next attempt at healthier eating and exercise in more a more bearable attempt.
So all systematic reviews should hopefully end with recommendations.
For research and recommendations for practice. You've gone you've read all the literature in an area.
You definitely want to take a look at those. And so that's what I'm going to finish up with today.
With Review one, we came out with very specific recommendations to basically say, Please,
if we do this review again, can we find some better studies that don't have these issues?
So we wanted people to make their protocols available so we could tell what they
actually did in their analyses to use different methods for recruitment to please,
please talk about the relationship between the researcher and participant.
For those of you who might be doing a qualitative study,
I'm sure you will because you've heard from memory, but some people haven't had the benefit of that.
And to be explicit about your data analysis process from review to we found
that there wasn't a one size fits all approach to self monitoring and studies.
There are lots and lots of studies those conducted within our team that asked participants to self monitor.
We said they might want to think about offering participants a choice of tools and also that future research might
want to draw it more explicitly the thoughts that people have and the emotions generated by self monitoring.
So though lots of our studies talked about self monitoring, very few of them set out to look at that.
Very few of them were actually trying to understand the emotions people had.
It was that it was such an emotive experience for participants that they were bringing it up in the context of other questions.
So we thought here more research looking at that specifically might be useful.
And finally, for reframing,
we found it certainly seemed an important technique for some people and there didn't seem to be any academic literature on it.
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.
Cognitive restructuring and for recommendations for practice,
we found that people used a really wide range of strategies in self-directed weight loss
and it might be that studies want to encourage people to use more than one strategy,
try them out, see how they work for them. There might not really be a one size fits all approach here.
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
a tool to aid analysis to help hopefully mitigate the phenomenon of shame that was leading to abandonment of self-monitoring.
This is something that seemed to be a really useful way for people to get away from the shame that they were experiencing.
And we thought basically interventions could benefit from explicitly encouraging their participants to do this.
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,
and that may well lead to the experiences of shame, which then lead to them abandoning their attempt.
And I think also what this pointed out to us was those we are not operating in a bubble and we cannot roll
out these interventions without thinking about the broader context of societal discourses around obesity,
around self-knowledge, around health, around personal responsibility.
And finally, with the third review, looking at reframing,
we thought that weight loss interventions could benefit from thinking about ways that they describe their interventions.
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,
it might be helpful for you to think about this as changing your way of life instead of conceptualising this as a diet.
And we found that programs might be able to benefit their users if they aid them to change
the language and the metaphors that they use and particularly reflect on past experiences.
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.
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.
And learning from those and reflecting on those instead of essentially ignoring them might be a good way to move forward.
So in conclusion, definitely worth it to do qualitative, systematic reviews here because we identified new strategies that we wouldn't
have found if we just looked at the academic literature of intervention reports.
The Maddocks synthesis, I thought was a very, very useful tool.
And for people who haven't done qualitative syntheses before, I found it quite intuitive and easy to follow approach,
whereas I think some of the other ones might be a bit more daunting and it definitely facilitated rich comparisons.
And finally, the reality was our ability to draw firm conclusions and if you read the limitation sections
of all these three papers was limited by the quality of the studies that we included.
And particularly, it was difficult to determine if what we were reporting really reflected the experiences
of the participants or if it was reflecting the researchers own take on the situation.
So very happy to take questions. That's a picture of my son looking very quizzical.
I'd like to put him up there because I had him whilst I was doing my PhD and doing this research.
Great. Thank you.