The overall aim of this paper was to conduct a comprehensive process evaluation of the previously established successful SHED-IT weight loss program for men. Our findings indicate that most men undertook SCT-based tasks including goal setting and monitoring of weight, physical activity and dietary intake. However, utilisation of social support networks and reward selection was poor. Of the SCT-based tasks, the most critical for success were goal setting and weekly weight monitoring, which were independently associated with weight loss. The Online and Resources versions of the SHED-IT program performed equally well, with no differences in weight loss, engagement in SCT-based tasks, or perception of program quality or program impact. The SHED-IT program was perceived to be supportive, enjoyable and beneficial.
A major finding of our study was the association found between various program tasks and behaviour change. While monitoring of all SCT-based tasks correlated with improved body composition, a multiple linear regression model demonstrated that goal setting and weekly monitoring of weight were the most important predictors of weight loss in this cohort of men. This model found that setting all nine goals equated to an additional weight loss of 2.9 kg and those who monitored their weight every week for the 3-month intervention had a corresponding additional weight loss of 2.7 kg compared with those who did not engage in these activities. This aligns with findings from a recent meta-regression of 122 physical activity and healthy eating behaviour change interventions, in which interventions with a self-monitoring component were significantly more effective than those without []. This finding also supports Bandura’s notion within SCT that self-regulatory behaviours are an essential component of successful behaviour change. According to Bandura (1997), self-regulatory behaviours rise to become the most important component of behaviour change when the behaviour of interest involves skills that people already know or can quickly learn (e.g. the motor skills required to perform physical activity) [].
Although goal setting was an important predictor of success, it is important to note that only half of the dietary and exercise goals the men recorded were considered ‘SMART’. This is important as research has shown that setting SMART goals increases the likelihood of goal attainment whereas non-specific goals reduce self-efficacy, which has a negative impact on subsequent goal setting []. Despite explicit instructions and multiple examples, this finding suggests that men still have difficulty understanding SMART goals and will require additional support in future programs. It is plausible that men who were more ready to lose weight prior to commencing the study were more compliant with program activities, which may have created a spurious association between compliance and weight loss. However, a recent systematic review of goal setting and behaviour change in adults supported our finding, by demonstrating that goal setting leads to changes in dietary and exercise behaviours []. Similarly, regular self-weighing enables self-evaluation of progress and further reinforces desired behaviours, thus contributing to weight loss []. In addition, a number of recent papers have demonstrated that self-regulation is the most powerful construct within SCT to explain and predict physical activity behaviour [-], dietary behaviour [,] and weight loss [] across a variety of populations. Therefore, the current research supports our observation, suggesting an important role for both regular self-weighing and goal setting in promoting weight loss in men.
While, in general, men completed the designated SCT-based tasks, most did not document rewards for achieving their goals. Furthermore, the proportion of men engaging in this activity reduced by half between the first and third month of the intervention. The reason for this lack of reward documentation during the SHED-IT program is unclear, but may be because the participants did not find the activity helpful for weight loss, chose to keep the rewards to themselves, lost motivation over time, or had an initial lack of ideas for good rewards. Alternatively, some men may have viewed weight loss as the reward without needing to motivate themselves with additional extrinsic rewards. Interestingly, when men did set rewards, the majority involved going out for dinner, drinking alcohol, or having a night out. This supports previous research demonstrating that men value weight loss programs that are not overly restrictive [], and that allow them to socialise and enjoy energy-dense luxuries on occasion [].
Overall, most men did not engage with the social support task in the Support Book. Less than 25% of men recorded strategies to engage social networks, and one-third of these were deemed to be poor quality because they recorded themselves as their support person rather than other people. Although the reason for the poor uptake of this activity is not known, it is possible that its importance was not sufficiently emphasised, that the activity was not well understood, or that the men’s previous exposure to this style of documentation or thinking was limited. In addition, sociological literature on men’s health shows that men prefer to engage in lifestyle programs that they can complete independently [], and thus the men may not have valued the idea of asking for help or support. Despite this, social support has been found to increase both intervention compliance and weight loss [,]. As such, identifying strategies that improve compliance with this activity may be warranted. It is also important to note that social support is not the only socio-structural factor outlined in Bandura’s SCT. However, targeting and operationalising this construct remains a difficult task as it represents a multitude of factors above and beyond social support networks []. These include ethnic group membership, education and intelligence, socio-economic status, the built environment and access to local facilities []. To improve study outcomes, future studies should explore novel ways to operationalise this construct above engaging social support networks alone.
Compliance or adherence to program tasks has been acknowledged as a major limitation of weight loss interventions, with the Internet as an engagement medium being identified as a particular risk. Indeed, attrition rates have been reported to exceed 40% for internet-based weight loss research []. Despite this, the current study had an attrition rate of only 20% for both intervention groups, which is similar to the average attrition rate of 21% for weight loss interventions in general. This suggests that, despite having no face-to-face contact, SHED-IT is as effective as other weight loss program formats in men. In addition, this is supported by our findings that overall weight loss, program engagement, perception of program quality, and program impact were similar for both the online self-monitoring and paper-based self-monitoring versions of SHED-IT.
A significant strength of the SHED-IT weight loss community program was its theoretical structure. Most weight loss interventions are not theory-driven, or use theory only as a loose framework, which is known to weaken the intervention effects []. As noted previously, the SHED-IT program was informed by Bandura’s SCT and was constructed to explicitly target the key behaviour change mediators specified in the theory. A systematic review of studies using the Internet as a medium for delivering health behaviour change programs demonstrated that, while only 20% of interventions used or mentioned theory as an intervention technique, a greater use of theory improved effect sizes, particularly those extensively incorporating theory into their program []. This review also demonstrated that goal setting, self-monitoring, social support and reward provision all have a significant, positive influence on behaviour change []. While all SCT-based tasks correlated with improved body composition in the current study, goal setting and weight monitoring were the strongest predictors of weight loss. Therefore, the combination of SCT-tasks used in this study improved weight outcomes in men.
Overall, men found the program to be beneficial and to provide sufficient support for their weight loss endeavours. Of particular interest, the men reported that the DVD was enjoyable to watch, improved their understanding of how to lose weight and approximately one-third of men watched the DVD more than once. These are important findings, given that the DVD was introduced to improve the scalability of the intervention by replacing the face-to-face information session of the pilot study []. Of note, both groups reported similar engagement with the program and both groups indicated that they would recommend SHED-IT to a friend, suggesting that the online self-monitoring and paper-based self-monitoring versions of SHED-IT were equally effective in engaging men. Interestingly, compliance with exercise monitoring was greater for the Online group compared to the Resources group. Although this may have been a chance finding due to the number of comparisons tested, it may also have been a function of task-difficulty. The online exercise diaries utilised established exercise databases and automatically calculated kilojoules burned during exercise, which eliminated the need to perform time-consuming calculations []. Therefore, the findings of the current process evaluation support the use of the Internet as an effective medium for weight loss intervention in men and suggest further examination is warranted.
A limitation of this study is some participants did not return their Support Book and the extent to which these were completed cannot be determined. However, the overall retention of participants in the trial was strong []. In addition, this study cannot confirm whether completion of the Support Book resulted in greater weight loss, because the Support Books were collected immediately prior to the assessment and not monitored throughout the intervention period. This could be investigated in future trials. This study contained several strengths including recruitment of a community sample of men, comprehensive tailoring of intervention materials to appeal to men and use of an extensively validated behaviour change theory. Aside from assessments, the SHED-IT programs involved no face-to-face contact and were considerably lower in intervention intensity than previous male-only weight loss studies []. The current analyses allowed for a comprehensive process evaluation, which provides valuable information to inform the development of novel obesity treatment strategies that engage men.
Currently, there is a dearth of research regarding how to engage men in weight loss programs and how to create effective programs that are tailored to their interests. Although we have previously established the efficacy [[13
]] and effectiveness [[17
]] of the SHED-IT program, this was the first study to determine which program components were most strongly associated with success. In addition to informing future refinements of the program, the current findings may help to encourage and inform other weight loss interventions for men, which are urgently required [[5
]]. In summary, based on the findings of the current process evaluation, we make the following recommendations for the development of such interventions:
Face-to-face information sessions or tailored intervention components may not be required for men to feel sufficiently supported in weight loss programs. Despite being considerably lower in intensity than other programs, men felt that the Online and Resources-only modalities provided them with sufficient support to lose weight.
The quality of strategies (e.g. gender tailoring selection of behaviour change techniques,) and information in the resources may be more important for men than a particular treatment modality. Both the Online and Resources groups were equally satisfied with the program and would have recommended the program to their friends.
Goal setting and weekly weight tracking were found to be the key program components associated with success for men.
Men may require additional information, examples or strategies to be able to successfully set S.M.A.R.T. goals, particularly for dietary and physical activity behaviours.
Future studies should pay attention to men’s initial weight loss expectations, particularly in the context of setting goals. Initially, approximately 25% of men who set a weight-related goal were aiming to lose more than the recommended ½ to 1 kg per week and 33% of men did not achieve their first target.
Despite being key behaviour change strategies outlined in Bandura’s SCT [,], setting social support strategies and rewards for success were not associated with improved treatment outcomes for men. However, it is important to note that men experienced considerable conceptual confusion with the social support task, with approximately 50% of men listing themselves as their own social support.
For men, physical activity goals were predominantly related to accessible lifestyle activities such as walking/ increasing step counts. Future studies with men should include a strong focus on these activities, which do not require specialised knowledge or skills.
When trying to improve eating habits, the most common goal for men was to reduce junk food intake, particularly in the first month. Given the large proportion of men’s energy intake that comes from non-essential foods [], this is an important finding and these goals could be encouraged in future programs