Managing obesity in men

What motivates men to lose weight?

Tackling obesity is a key government priority. Losing weight can improve people’s health in a range of ways, but also has an economic impact. It is estimated that the direct costs of obesity to the NHS are in the region of £6.3 billion for 2015, whilst local authorities are estimated to spend an extra £352 million providing social care for people who are severely obese.

Although it is not mandatory for local authorities to provide obesity interventions such as weight-loss programmes, it is clear that helping people to lose weight can support a range of public health targets.

More men than women are overweight or obese in the UK – 66% of men compared with 58% of women . In addition, men are less likely to lose that weight unsupported: recent NIHR research suggests that the chance of an obese person returning to a healthy body weight is 1 in 210 for men and 1 in 124 for women.

Despite this, men may be less likely to recognise that they are overweight or obese, and are less likely than women to engage with weight-loss programmes. A review of two large NHS weight-loss programmes found that only around 10% of referrals were men. But when men do engage with a weight-loss programme, they do well, with lower drop-out rates than women, and some evidence they may lose more weight than women.

What attracts men to join a weight-loss programme?

Men may be motivated to join a weight-loss programme if they understand their weight is a health issue – for example if they receive a diagnosis of a weight-related health condition from a GP or other health professional.

However, there is evidence that men are not attracted by standard weight-loss programmes. NIHR research suggests that men may find use of the term ‘dieting’ off-putting and to see weight-loss groups as primarily for women. Men may prefer programmes which emphasise healthy eating or physical activity instead.

Men seem to favour community settings and some men are attracted by the idea of a ‘men-only’ weight-loss group. For example, some studies have found that weight-loss programmes run through professional sports clubs to which men may feel a strong affiliation are popular and effective.

Key implications

More men than women are overweight or obese in the UK, but men are less likely than women to join weight-loss programmes. They may be less likely to realise they are overweight or obese, or the health risks associated with excess weight.

A diagnosis of obesity or an associated health issue may be a strong prompt for men to take action about their weight.

When men do join weight-loss programmes, they do well, with lower drop-out rates than women and some evidence they may lose more weight.

Men are more likely to join weight-loss programmes which:

• Emphasise healthy eating and physical activity, rather than ‘dieting’
• Are run through community settings, for example sports clubs to which some men may feel a strong sense of affiliation
• Offer a ‘men only’ group option.

Components of a successful weight loss programme for men

Although men are more likely than women to be overweight or obese, they are less likely to seek help or join a weight loss programme. If men do join a weight loss programme, the evidence suggests there are certain factors which are more likely to make the programme successful.

As might be expected, there is clear evidence that men are likely to lose weight through a reducing diet. But for men (as for all adults) the combination of a reducing diet with physical activity seems to be the most effective approach, and men seem to particularly like having a physical activity component to any weight loss programme.

What weight loss programmes work?

The evidence suggests that men do well in group settings, with some favouring men-only groups, although some also value individually tailored advice in addition. There is also some evidence that men favour factual information, and possibly the use of technology or props to illustrate weight loss and exercise patterns – such as pedometers, for example.

Commercial weight loss programmes achieve results as good as NHS programmes, but most are predominantly female and men are much less likely to enrol in these groups.

Interventions in community settings, like sports clubs or workplaces, are more attractive to men than healthcare settings. In particular, studies have found that programmes run in sports venues to which men felt a strong connection demonstrated low drop-out rates and high participant satisfaction. Men in these programmes also valued the sense of camaraderie and ‘team spirit’ which came from working in a supportive group environment with other similar men.

There is some evidence that the use of behavioural change techniques, such as self-monitoring and goal-setting, may be effective as part of a weight loss programme for men. However there is no clear evidence to suggest whether any particular combination of behaviour change activities is more effective than any other.

Football fans in training - a weight loss programme for men

A group of 747 men were randomly assigned to receive either the Football Fans in Training (FFIT) intervention or go on a waiting list to start the programme in 12 months’ time. The intervention comprised 12 sessions of dietary and exercise advice, held at a local professional football club, and a pedometer-based walking programme.

After a year, the men who had completed the FFIT programme had lost nearly 5kg more than those who had not. They also demonstrated improvements in blood pressure, dietary habits and alcohol consumption compared to the waiting list group.

You’re doing it in a group, it’s so much easier. You’re encouraging each other and you’re happy to see other people getting on and losing weight – not just the losing weight.

Participant, Football Fans in Training

Is running a targeted weight loss programme for men cost-effective?

At the moment there is limited evidence about the cost-effectiveness of targeted weight loss interventions for men. However, the Football Fans in Training programme carried out a cost-effectiveness analysis of this particular intervention. This found that the intervention is likely to be cost-effective based on the findings of the evaluation at 12 months. Projections over a longer time period also found that the intervention was cost-effective.

Key implications

Evidence suggests that the following components are associated with successful weight loss programmes for men:

• A combination of a weight reducing diet (not crash diets) with physical activity.
• A group environment (some men may prefer men-only groups) with some individually tailored advice
• Use of behavioural change techniques such as goal-setting or self-monitoring, and perhaps the use of technology or props such as pedometers.
• A sense of camaraderie and mutual support. One way in which this has been achieved is through programmes run through the professional sports clubs which participants support, although this type of programme may not suit all men.

There is limited evidence on what helps men maintain weight loss, although behaviour change techniques may help in some circumstances.

NICE guidance on management of obesity provides more detailed information about the components of successful weight loss programmes for adults in general, including many of the elements above. This new evidence adds to this in terms of the specific elements that are most important for men.

About the evidence on male obesity

What is the research that this Highlight is based on?

The findings discussed in this Highlight are from two NIHR studies:

A systematic review, funded by the Health Technology Assessment Programme, into the evidence base for the management of obesity in men: Robertson C, Archibald D, Avenell A, Douglas F, Hoddinott P, van Teijlingen E, et al.Systematic reviews of and integrated report on the quantitative, qualitative and economic evidence base for the management of obesity in men. Health Technol Assess 2014;18(35)

A trial, funded by the Public Health Research Programme, of a weight loss programme for men run through football clubs in Scotland: Wyke S, Hunt K, Gray C, Fenwick E, Bunn C, Donnan P, et al.Football Fans in Training (FFIT): a randomised controlled trial of a gender-sensitised weight loss and healthy living programme for men end of study report. Public Health Res 2015;3(2)

How strong is the research evidence in this area?

There is limited evidence from the UK on the most effective weight-loss approaches for men. Those that exist mainly reflect the experience of white, middle class, middle aged men, and there is a lack of longer term data.

The systematic review discussed here is the largest and most complete analysis of all the available evidence. Although the evidence didn’t provide a complete picture, findings were consistent across a number of studies. In addition, the Football Fans in Training evaluation reinforces many of these conclusions, and the men in this study were from all socio-economic groups, though few were from ethnic minority groups.

How does this fit with current guidance on managing obesity?

The National Institute for Health and Care Excellence (NICE) has published a number of guidelines relating to the management of obesity. There is no NICE guidance that specifically covers the management of obesity in men, but much of the general adult guidance is applicable and reflects the findings of the research discussed here. For example, NICE recommends the commissioning of programmes which include dietary advice, physical activity and behaviour change, provide clear goals and targets for weight loss and physical activity, are tailored to the needs of different groups (including men), and are delivered by trained professionals. The evidence discussed here adds detail on which of these elements are likely to work best for men.

What's happening next?

The NIHR is funding further work in this area, in particular a longer-term follow-up study of Football Fans in Training, to see if the men involved have maintained the weight loss they achieved in the original programme. This will report in September 2016.

The Football Fans in Training programme is now being tested within a number of other settings including rugby clubs, European football clubs, and prisons.

The NIHR is also funding a range of other research relating to the management of obesity, including studies looking at prevention of obesity in children, strategies for maintenance of weight loss, and the use of bariatric surgery. You can explore some of this by visiting www.nets.nihr.ac.uk/projects and searching for ‘obesity’.

The Men’s Health Forum has published a more detailed guide on commissioning weight-loss services for men, based on the systematic review summarised in the highlight.

Disclaimer: This report by the NIHR Dissemination Centre, funded by the Department of Health, presents a synthesis of independent research. The views and opinions expressed by the authors of this publication are those of the authors and do not necessarily reflect those of the NHS or the Department of Health. Where blogs, sound recordings and verbatim quotations are included in this publication the views and opinions expressed are those of the named individuals and do not necessarily reflect those of the authors, the NHS, the NIHR or the Department of Health.

Addressing gender, fitness and health benefits

In the United Kingdom 67% of men are overweight or obese. Weight is associated with an increased risk of cardiovascular disease and diabetes. 75% of premature deaths from coronary heart disease are men and twice as many middle-aged men than women have diabetes. Last year the Men’s Health Forum showed that weight loss programmes only helped 0.2% of the 14 million overweight and obese men in England. There are many reasons why men do not use these services an important factor seems to be that most weight loss services may not reflect the needs of men and tend not to appeal to them. One solution is to make weight loss services gender specific.

How to make weight loss services work for men

Losing weight based on dietary changes alone does not appeal to men. Weight loss programmes for men should focus on improving health and fitness, rather than weight-loss and dieting. The Men’s Health Forum advises to avoid marketing and talking about weight loss but recommends instead concentrating on improving health and fitness. A male friendly approach is about paying as much attention to physical activity as dieting.

Most men do not like strict diets and are somewhat anxious about looking thin, so it is important to remind men of the health gains associated with losing weight, for instance feeling fitter, coming off medication or reduced incidence of erectile dysfunction.

Men are often motivated to act on their health when they have a health scare. After a scare, friends and family offer most support for men to act. If men have support from medical professionals, family and their peers, they are more likely to become healthy and fit. Once men are engaged, they are more likely than women to complete programmes and achieve their goals. Sports, sports settings and physical activity are not only important for improving fitness and engaging men, but also help to create peer support.

Men's Health Forum and Practioners Guide on Weight Loss Services for Men

The Men’s Health Forum is commissioned by Public Health England to work with local weight management teams in North Somerset, Cornwall and Hounslow to improve their community health improvement programmes.

The work includes training on how to work effectively with men, adapting marketing materials to appeal to men and developing resources targeted at men. The programmes are currently being evaluated by Leeds Beckett University and initial findings show successful engagement with men and weight lost by the majority of participants.

The Men’s Health Forum has published a practitioner’s guide with PHE. The guide ‘How to make weight loss service work for men’ gives Local Authorities, CCGs and commercial organisations insight, top tips and recommendations on the interventions, settings and resources that work for men. The approach is based on a systematic review of evaluated weight management programmes for men led by the University of Aberdeen, in which the Men’s Health Forum was the lay partner.

About the author: Tracy Herd, Deputy Chief Executive of Men’s Health Forum

Sinners to Saints: Bringing FFIT to the Premier League

Recently, the Public Health team at Southampton City Council brought Football Fans in Training (FFIT) programme to Southampton. This was the first iteration of the 12-week FFIT programme in an English Premier League Football Club, and so working as part of the Public Health team, I conducted an evaluation to compare whether FFIT could be generalised effectively into a new setting.

Working in collaboration with the charitable wing of Southampton FC (known as the Saints Foundation) and in conjunction with the Scottish Premier Football League (SPFL) Trust, the agreement was to pilot the programme with approximately 15 suitable participants and to conduct the evaluation using a mixture of quantitative and qualitative methods.

Kick off

The Saints Foundation selected a suitable coach to run the programme in Southampton and attended a two-day SPFL Trust FFIT coach training. An emphasis was placed on fidelity to the original FFIT programme, which was enhanced by using  detailed FFIT delivery manuals. The SPFL Trust also supplied participant programme booklets and an equipment kit containing weighing scales, height stadiometer, blood pressure machine and ‘Eat well Plate’ demonstration kit.

The programme was promoted during the last match of the 2014/15 football season, using adverts in toilets and in food halls. Eighteen eligible men, all overweight or obese, enrolled on a first come, first served basis. Fifteen completed the first 12-week FFIT delivery, which began at the end of March 2015.

Final score

At 12 weeks men had lost an average of 6.9kg, or more than 6% of their initial weight - a similar result to the original FFIT trial. Furthermore, two thirds of participants achieved 5% weight loss – enough to lead to health benefits such as a reduced risk of diabetes.

The 12-week FFIT programme cost per participant (based on 15 participants) was as low as £87.28, mainly due to The Saints Foundation not passing on coach salary or facility rental to the FFIT Southampton programme. This weight-loss programme is therefore cost-effective if participants maintain 1Kg of weight loss for a lifetime, according to the usual boundaries set by the National Institute for Health and Care Excellence (NICE).

Post-match analysis

Shortly after the delivery of the 12-week programme, a coach interview, a focus group (five participants), and a participant questionnaire (11 of the 15 programme completers) were conducted as part of the evaluation. All participants who completed the questionnaire believed their involvement to have been successful, a success driven mainly by the trio of ‘football’, ‘team’ and the nature of the ‘programme’.  Although not cited as a primary reason for success, the characteristics of the coach were believed to be ‘important’ or ‘extremely important’ in the success of the programme. The coach created an atmosphere that was safe, fun and encouraging, underpinned by a respect for the participants. They in turn respected his professionalism.

Participants believed that the continuation of some form of weekly activity sessions after the 12-week programme had finished was vital to the continuation of their success. These sessions would maintain the integrity of the ‘team’, which was a powerful form of support  in maintaining the physical activity and healthy eating changes they had made. Twelve of the original fifteen men completing the programme continue to meet up for weekly physical activity sessions.

A team sport?

The power that the participants drew from the union of ‘football’ and ‘team’ and the lack of belief in their individual, intrinsic, abilities to maintain the changes without them, suggest that long term weight maintenance and behaviour change is going to be a challenge for some of these individuals. The men did not believe that the FFIT programme itself could be adapted to protect against this problem.

Longer-term success may be possible if the participants are able to continue to maintain their involvement with the ‘team’, although it is not sustainable for the FFIT Southampton programme to continue to fund weekly sessions of physical activity ad infinitum. Additionally this reliance on ‘team’ expressed by this cohort of football supporters who have successfully engaged with the FFIT programme, and reached impressive weight loss goals, may suggest that this may not generalise to men who are less connected with the idea of a ‘team’ and/or football, but this would need to be evaluated.

In conclusion, the first Southampton FFIT programme delivery appears to have been a success. A second cohort has recently completed the programme and a third cohort is underway. Future commissioning decisions will be made after reviewing subsequent outcomes from these and future cohorts.  It is also hoped that further data will be collected on the first cohort at 12 months so that further comparisons with the original FFIT trial can be made and the cost-effectiveness of the programme can be further reviewed.

About the author: Robin Poole. Specialty Registrar in Public Health

The view from a specialist obesity clinic

In our medical obesity clinic, there are significantly greater numbers of women than men referred, despite high levels of obesity in men. We find often find that a recent health scare, such as diagnosis of diabetes or a fatty liver, has motivated the men to think about losing weight and improving their health.

The clinic is aimed at patients with severe and complex obesity, is jointly run by a dietitian and physician, and is accessed via GPs and the community based Leeds Weight Management service. In our initial assessment, we look at the history of weight gain. Many men report that a reduction in activity was a factor; with the local interest in rugby and football, many may have played the sport (with several weekly training sessions) but then had to stop through an injury, work commitments or a change in family circumstances. This decrease in activity (along with continuing to eat and drink the same) has often contributed to weight gain over the years.

We find that men are less likely to have tried formal diets, such as attendance at slimming clubs, diets through the local GP practice or very low calorie diets, compared with women. They tend to say that they have ‘watched their diet’ or their partner has encouraged them to watch their calorie intake. Men often try to increase their activity to help with weight loss.

Although they are less likely to have attended slimming clubs, many state that they have found the group sessions run by Leeds Weight Management very helpful. In the Leeds Weight Management group, all attendees have a significant amount of weight to lose and most have significant comorbidities in contrast to the usual members of slimming clubs. Men have reported that this makes them feel more comfortable about attending, even though it is a mixed group. The Leeds Weight Management sessions focus on healthy eating, including portion sizes, goal setting and also being more active. All attendees have access to local leisure centres at reduced cost.

As the men have been through a community weight programme before referral onto our clinic, most will have started to address portion sizes, decrease snacking and trying to be more active. This focus continues in our clinic. Some will report that they are doing a significant amount of exercise, but it is important to get the correct balance so activity can be maintained. We have had a small number of men who have attended slimming clubs; one was so successful that he is now a group leader!

The clinic focuses on improvement in comorbidities, in addition to weight loss. Currently advice is on an individual basis and we will encourage men to continue with self-monitoring and setting small achievable goals. Some men will use apps on their smartphones to monitor their diet and activity.

We are currently expanding our clinic and will be working more closely with Leeds Weight Management. This may give the opportunity to develop men only groups in combination with leisure centres.

New NIHR research supports much of what we are doing – for example, confirming the factors that encourage men to seek help with their weight, and providing an example of a programme that uses an interest in sport to support weight loss. We will be thinking about how we can implement these findings, and those from current research projects, in practice.

About the author: Mary O'Kane, Consultant Dietitian in Adult Obesity