Perceived Barriers to Weight Management: A Qualitative Study on Overweight and Obese Women in Shiraz, Iran

Background: Obesity is among the most important health challenge, with an increasing incidence in current century. It is considered as an important factor lead to social unacceptability. Almost in all societies women are more careful and sensitive about their beauty and appearance than men. The purpose of this study was to assess perceived barriers to weight- loss programs among women with obesity in Shiraz. Method: This qualitative study was conducted using eight semi-structured focus group discussions (FGDs) among 48 women and seven in-depth interviews with key informants. All eligible participants for FGDs were selected through a public call in Shiraz. Results: Dietary, socio-cultural, supportive- psychological and economic issues were identied as the main barriers to weight-loss programs. Conclusion: Data collected from the individual and group interviews provided extensive information on the strengths and weaknesses of dietary programs. The results of this study can be used to improve the services for obese and overweight people as well as expanding the knowledge of dietitians for developing more ecient weight-loss programs.

The increasing rate of obesity is a critical public health challenge worldwide. According to the World Health Organization (WHO) in 2014 more than 650 million adults around 18 years and older, were obese (1). Based on the latest WHO estimates in European Union countries, overweight affects 30-70% and obesity affects 10-30% of adults (2(. In Iran the prevalence of overweight and obesity among men and women is 42.8% and 57.0% respectively (3).
Obesity is a chronic, progressive disease that is di cult to treat and is associated with many harmful health effects like diabetes, hypertension, dyslipidemia, and cardiovascular diseases. Sustained weight loss is associated with prevention, alleviation and resolution of many obesity related comorbidities (4,5).. Studies have indicated that obesity effects on individuals' health and their psychological state. The analysis emphasizes the role of obesity in depression, anxiety, body dissatisfaction, and low self-esteem (6).
To combat the mentioned problem, it is necessary to nd proper strategies to reduce the rate of obesity and overweight. A large number of weight-loss programs, which combine diet, physical activity and behavioral change programs are effective only in short term and it is di cult for individuals to maintain a diet and keep the lost weight (7). It has been shown that 90 to 95% of obese individuals, who manage signi cant weight loss, will regain their weight over 3 to 5 year follow ups (8).
Several investigations studied the perceived barriers to weight-loss programs such as poor socioeconomic conditions, mental and psychological problems and poor knowledge about weight loss and diets (9,10). Regarding the effects of obesity on physical and mental health, in the current study we aimed to explore the reasons which brings about failure to maintain the weight-loss programs in women.

Methods:
Study design and participants: In the current study both, quantitative and qualitative data were collected. To collect quantitative data height, weight, waist circumference and hip circumference were measured. To acquire a deep awareness of the issue in qualitative study a total of seven in-depth interviews with experts and eight focus group discussions (FGDs) with obese women were held.
The participants in focus group discussions lled out a demographic questionnaire at study entry. For FGDs a topic guide was prepared ( Table 1). The guide included 13 questions designed according to the purpose of the study and participant groups. Out of the 13 questions, the rst 5 ones were ice-breaking questions. Each question also was followed by some probing questions and the content of the topic guide was seen and approved by a group of experts including professors in nutrition. Participants in the group discussion sessions included 48 women, aged between 18 and 55 years old, single and/or married, with different educational and occupational levels, which were selected based on the inclusion criteria of the applicants (Table2, 3). They were invited through a public call in local newspaper in Shiraz, Iran. Each FGD was conducted with 5-8 participants and lasted for 45-60 minutes.
The research team for FGDs was included of a coordinator and two note-takers, who were all nutritionists. FGD sessions were held in a quiet area in the conference hall of Imam Reza clinic in Shiraz, and all interviews were recorded with interviewee's permission. At the end of the sessions, anthropometric and demographic data were measured and some gifts (included kitchen scale and scale) were given to participants. Then, we select seven key informants who were familiar with the eld of nutrition and also well reputed on their own expertise. The interviews were hold in their o ces and took them about one hour. They included two psychologists, two nutritionists, two people with obesity and one sociologist. In-depth interviews were coordinated by the chief researcher with the aid of topic guide.
Data Analysis: Semi-structured interviews were analyzed by thematic analysis.
The MAXQDA11 software was used to sort and categorize the data. In the rst step, interview le was transferred to the software, and in the next step, primary codes were extracted from the data. Then repeated codes were removed and the similar codes were merged to make emerging themes and Results : Anthropometric and demographic information participants are presented in Tables 2 and 3, respectively . A total of 1429 initial codes were obtained from FGDs, and after categorizing, four main barriers were resulted ( Table 4). The more repeated barriers were identi ed as main barriers and each of them has some subgroups.
Our FGDs participants pointed to some barriers categorized as dietary barriers. This group of barriers was the most mentioning barrier claimed by them; it included some subgroups such as food taste, diet and satiety, duration of effect, hard-to-follow and health problems. They pointed to restrictions imposed by the diets like restricted access to speci c foods and the fact that the diets were not based on their taste and interests. It was believed that dealing with these problems whilst on weight loss diet, was the reason for failing to follow the diet. In response to the question "Do you think weight loss diets are desirable in terms of taste, ll fullness and diversity?" a woman said: "While on diet, I always feel hungry thus I cannot follow my diet ". Another women in response to a question about disadvantages of weight loss diets said: "It takes a lot of time-that a diet works". A young woman in response to the question "Do you think longterm follow-up to weight loss regimens has health implications?" replied: "While on diet, my body gets weak, and I get sick too often, as if my immune system is getting weaker ".
The second barrier which mentioned by the participants was social and cultural barriers. Participants indicated the lack of social facilities and lack of knowledge about obesity in society cause they left the diet. Role of party or traveling and maternal role were commonly mentioned factors that are threatening weight loss efforts. They also indicated that while they are on diet, their learning and studying ability was reduced and they cannot manage their diet program at work .Women in response to a question about the psychological support of the society :"Obese adolescents are not accepted in the community but no one supports me while I am on a diet ". A woman told about the impact of her social role, as a mother, on the weight loss diet: "When I leave the table sooner before others, my children also follow me and do not eat all their meals ".
The third barrier was psychological and supportive barriers. The participants stated that obesity caused many psychological problems, including lack of self-esteem and dissatisfaction .furthermore, the need for mental support and encouragement by family and friends was called by individuals as a stimulant factor. One of the women in response to a question about psychological support of family and friends: "No one helps me or encourages me to follow my dietary programs, and I cannot do it without others' encouragement".
The last barrier which indicated by the participants was economic barriers. economic problems and food costs and cost of regular visits were mentioned as a main barrier to maintain their diet. Participants believed that attending in gyms and providing dietary foods, cost a lot and they are not able to provide these items.
Women answered to a question about economic conditions :" each visit's price is too much for me and I have to go to the clinic on a weekly basis " and "After the rst few weeks, gradually I feel that the price of dietary items puts some pressure on me and I cannot afford it".
Each of seven key informants separately answered questions in 20-30 minute sessions. They pointed out four main barriers and according to their expertise present different aspect of each barrier in Table 5( at the end of the manuscript). •" Mental preparation of individuals priors to lifestyle change". ( sociologist ) •" The prescribed diets should be advantageous and cause no harm to individuals lifestyle". ( psychologist) • "The inadequacy of the diets to suppress the appetite for fatty foods ". • "Improving the quality of the community in terms of social health and healthy behaviors". ( sociologist ) • "Receiving support for achieving the desired condition avoiding failure and subsequent complications". ( psychologist ) •" Need for cooperation from other family members in order to make weight loss easier " .( obese woman )

Main barriers
Quotation from key informants in, in-depth interviews Economic Barriers •" Need for adequate nancial resources to access a diverse range of food items ". (nutritionist) • "Improving the knowledge of dietitians in order to prescribe based on the nancial situation of the client". (sociologist) •" Adopting the dietary program with the nancial situation of the clients". (Psychologist).
• "Need for su cient nancial support in order to follow a dietary program". (Obese women). Discussion:

Main barriers
According to the results of current study, several restrictions like dietary, social and cultural, psychological and supportive and economic barriers were the most barriers to weight loss programs. These barriers have been mentioned by some studies with the same issues (11,12).
The rst barrier was related to diet and in this regard, they referred to the lack of attention of dietitians to the particular conditions of each individual, such as family situations, occupation, and they also mentioned the effects of diet on their physical and mental health. Moreover, they considered it unreasonable to change their cooking style based on the dietary recommendations.
According to Amiri et al., adolescents who participated in a survey in 2010 complained about inadequate knowledge of the nutritionist and the low e ciency of their services (13). Kreany et al., also mentioned the problems regarding the avor and taste of prescribed diets (14). In addition Lopez et al. reported some barriers, such as mismatch between the diet schedule and working timetable, and unappealing food in the diet programs (15).
Obesity is believed to be widespread in the lower social classes; however, there are various relationships in socioeconomic status and obesity between countries at different stages of development (16). The presence of women in social elds was stated as a positive factor for success in weight-loss programs.
According to the viewpoint of our subjects, being employed as well as spending a lot of time out of home increased their sensitivity to their appearance and health. Besides, they stated in details about their role as mothers and its effects on following their diets, and they believed that being a mother could disrupt their focus on the program. (17). Similar to our study, female subjects in other communities have faced problems such as unsafe environments and time limitation for physical activity (18). Conversely, female participants in other studies pointed out the positive aspects of having jobs in following the diet, such as their income for using the health services and sport clubs (19). It has been proven that employed women are less likely to become obese and overweight than non-employed women (20).
The psychological and supportive issues were among the third group of barriers mentioned by our subjects. They emphasized the need for proper social support from people at various levels of society. Besides, they believed that following diet programs was accompanied by some degrees of emotional problems such as fatigue, discouragement and decreased self-esteem, and all participants indicated that these issues could be addressed if they were supported by other peoples. Sobal et al., reported that others behavior could affect the type, amount and timing of food consumption (21) According to Hammarström et al., it could be di cult to match the dietary habits ,including the type, composition and timing of food consumption with other members of the family or other relatives (20). In Alm et al. survey, female subjects believed that psychological support from people around them, such as family members, friends or tutors, was very effective in following the diet programs (19) Some studies indicated that feeling embarrassed at parties, lack of support from friends and family members, and dissatisfaction with the diet in the family and friends gathering all were barriers to the therapeutic diet (22,23,24).
Economic barrier was considered as the last barrier to weight control by our participants. Our participants explained various aspects of the economic barrier, including the cost of monthly visits of dietitians, purchase of dietary items, and attending sports clubs. Several studies highlighted the high cost of providing healthy foods as an economic barrier, and indicated the emphasis of dietitians on a group of some speci c food items such as meat, dairy and vegetables caused some individuals not to be able to follow the dietary programs for a long time (19,25). Furthermore, similar to our participants' comments, health practitioners in Woodruff et al. study indicated the lack of su cient nancial resources was a barrier for individuals to refer to nutritionists (26).

Conclusion:
The participants pointed to four main barriers regarding weight management programs. The included diet related, social, cultural, psychological/ supportive, and economic barriers. The results of this study con rm the key role of the dietitians in designing a proper diet. Furthermore, the supportive role of, the families and, friends in living a healthy life style should not be ignored. This study was approved by the Shiraz University of Medical Science. According to SUMS legislation, approval from the ethics committee isn't requiring for qualitative studies. All participants provided written informed consent prior to enrolment in the study.
• Consent for publication : Not applicable • Competing interests