Gender-sensitive community weight-loss programmes to address overweight and obesity in men: a scoping review

STRENGTHS AND LIMITATIONS OF THIS STUDY

  • To the best of our knowledge, this is the first scoping review undertaken to understand the gender-sensitive approaches to men’s weight loss in community settings.

  • A comprehensive literature search was undertaken assisted by an information specialist.

  • The findings were mapped to a pre-existing framework developed via thematic synthesis.

  • The review did not specifically set out to identify studies for diverse subpopulations of men including gay and bisexual men, immigrant men, and Indigenous men and may have missed targeted programmes.

  • The review only included articles published in English.

Introduction

Community-based weight-loss programmes are an effective intervention to help address the global epidemic of overweight and obesity.1–9 However, men typically show low levels of engagement with weight-loss programmes.10 11 A systematic review of randomised controlled trials (RCTs), for example, found that on average men made up only 27% of participants,11 while reports from commercial weight-loss services suggest men’s attendance as low as 11%.10

A major barrier to attendance is that men report feeling uncomfortable with traditional weight-loss programmes.12 Men report concerns that programmes are ‘female dominated’, incompatible with their needs and values and better suited to the needs of women.12 13 In addition, men report that attending programmes where participants are mostly female can lead them to feel embarrassed and ostracised, particularly in the absence of male peers.12 13

Gender is widely recognised as an important social determinant of health.14 Previous research has linked traditional masculine norms with poor engagement with healthcare services and a reduced likelihood to seek help for health issues.15 It is important, therefore, for health services to develop a gender focus when formulating ways to promote engagement and retention.

In response to men’s concerns with traditional weight-loss programmes, practitioners have increasingly drawn on ‘gender sensitive’ programmes16–18 which are designed to align with men’s values, ideals and patterns of social interaction.17 19 20 For example, programmes can be run in workplace settings or sporting clubs, and programme content can be designed to reflect men’s interests, ideals, aspirations and preferred styles of communication.10 The development of this intervention design is consistent with WHO’s calls for a ‘gender approach’ in addressing men’s health needs18 and addressing the call to implement ‘gender sensitivity’ in the current system.19 The intervention also reflects on the early initiative of gender sensitivity that captured the perceived beliefs, decisions and actions of health professionals towards gender differences.21

The past decade has seen a rapid growth in the application of gender-sensitive weight-loss programmes to address men’s overweight and obesity.5 18 20 However, to the best knowledge of the authors, no review has systematically examined how this novel intervention design in the context of weight management interventions for men has been conceptualised, operationalised and investigated. Published reviews are limited to investigating the effectiveness of male-only weight-loss programmes quantitatively,22 exploring the context and mechanisms of weight-loss management on men using a realist perspective,23 and exploring the potential for delivering health promotion interventions through professional sporting organisations.5

Therefore, the purpose of this scoping review is to (1) identify how gender-sensitive approaches have been operationalised in terms of programme design, the countries and social contexts where the programmes have been carried out, and the sociodemographic characteristics of programme participants; (2) identify common programme components, as well as challenges and difficulties in conducting programmes (including adverse events); (3) identify the type of evaluations that have been conducted and (4) identify insights provided by these evaluations.

Methods

This scoping review was guided by the Joanna Briggs Institute manual for scoping reviews using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for scoping review approach for reporting.24 The below information provides a summary of the methods used. A fuller detailed description of the methods is available in online supplemental file 1.

Supplemental material

The research question was developed using the Population, Concept and Context formulae.24 This was determined as men who are overweight or obese and participate in weight-loss interventions that apply a gender-sensitive approach. A programme was considered gender sensitive if it targeted men and was explicitly designed with consideration of men’s ideals, preferences and cultural values.

Search strategy

A database search was conducted using EBSCOhost platform (including Academic Search Complete, CINAHL Complete, Global Health, Health Source: Consumer Edition, Health Source: Nursing/Academic Edition and Medline Complete) Google, Google Scholar and Open Access Theses and Dissertations platform and Scopus up to March 2022. Details of the search strategies are available in online supplemental table S1. An updated search was undertaken on 31 September 2023 to ensure all relevant articles were captured.

Eligibility criteria and study selection

Inclusion criteria and exclusion criteria

Inclusion criteria were literature that specifically addressed group-based weight-loss programmes for men using a gender-sensitive approach offered in sport-based and/or community settings. There was no limit placed on the year of publication for quantitative evidence while for the qualitative evidence only studies published since the completion of a review in 2015 were included.23 Only full-text articles published in English were considered. Details of these criteria are provided in online supplemental table S2).

Screening

All references were imported into EndNote referencing software (V.20.1) and Covidence review management platform to detect duplicates, perform title and abstract screening and full-text assessment. Three authors (YL, SAK and DN) independently screened titles, abstracts and full-text articles. Any discrepancy was resolved by discussion with a third reviewer (DA).

Data extraction

All eligible literature was charted using Microsoft Excel. Data fields (online supplemental file 1) were tested on 25% of the included studies. The test sample was reviewed and discussed for improvement. For qualitative studies, the extracted data were mapped on a modified framework comprising the thematic headings from a previous qualitative evidence synthesis on men and weight management.23 The modified themes are available in online supplemental file 1. Qualitative and quantitative components of mixed-methods studies were extracted independently for inclusion with corresponding evidence. One author primarily extracted the data (DN or YL) and all data were verified by a second reviewer (DN or YL or SAK). Any disagreement was resolved by discussion between the authors.

Patient and public involvement

There was no patient and/or public involvement in the study design or conduct of the study, as well as any plans to disseminate the results to study participants.

Results

Database searches and citation searches identified a total of 4617 records (figure 1). Of these, 40 full-text studies were included. These included 28 quantitative studies, four qualitative studies and eight mixed-methods studies (online supplemental table S3). The year of publication ranged between 2005 and 2023, with a peak of published studies in 2019–2020 (figure 2).

Figure 1
Figure 1

Preferred Reporting Items for Systematic Reviews and Meta-Analyses diagram.

Figure 2
Figure 2

Number of publications by year.

Country and demographics

Gender-sensitive programmes have been offered in multiple countries, including Australia (n=12), the UK (n=10), Canada (n=6), the USA (n=5), Ireland (n=2), New Zealand (n=2) and Germany (n=1), with further programmes being offered in multiple countries such as the Netherlands, Norway and Portugal.25

All programmes offered interventions for men who were overweight/obese (body mass index (BMI) >25 kg/m2) except two studies that included a mixed population of normal weight and overweight men. These are Save Our Sons (SOS)—an Australian study that only reported on men with health challenges in general,26 and POWERPLAY—a Canadian mixed-method study offering an intervention in the workplace setting.27 Among the studies reporting on men who were overweight or obese, one study referred to the weight of participants instead of BMI28 and two studies had a mixed population of those who were overweight and non-overweight29 30 (online supplemental table S3). 14 studies were targeted towards multiple populations. For instance, two studies from the UK and the USA targeted participants with overweight and obesity who were at high risk of having type 2 diabetes mellitus (English Premier League (EPL) Health and Power Up for Health, the Lorain County Urban League);30 31 and two studies in the USA focused on African-American men including Men on the Move (MOM)-Nashville and SOS (n=2);30 32 three studies focused on disadvantaged communities including low socioeconomic areas and/or regional areas, which were Power Up for Health and SOS in the USA and Sons of the West in Australia.26 30 31 In addition, three studies offered programmes to people over 50 years;29 33 34 two programmes (n=5 studies) focused on family relationships (Healthy Dads Healthy Kids (HDHK) (fathers and sons) and Dads and Daughters Exercising and Empowered (fathers and daughters)),35–39 and three further programmes (Slimming World, POWER and POWERPLAY) focused on participants in a commercial organisation.27 40 41

Programme settings

Programmes have been applied in a range of settings and contexts. The majority of programmes have been applied in sporting clubs. These include club-based training for club supporters (n=21); community-based (n=16); a combination of sport supporters and community resources (n=2); support to disadvantaged/hard to engage groups (n=5); chronic disease/at risk of chronic diseases groups (n=5); e-Health for self-help or reminder messages (n=8); workplace-based (n=2) and commercial organisation-based (n=1).

Programme design

All programmes used group-based, face-to-face interaction among participants facilitated by coaches, professional facilitators or speakers. In addition, eight programmes Self-Help, Exercise, Diet & Information Technology (SHED-IT), Fans In Training (FIT, and its variation Football FIT (FFIT)), EuroFIT, Rethinking Eating and Fitness (REFIT), MOM, POWERPLAY and Power Up for Health20 25 28 31 32 40 42–45 were supported by e-Health tools (ie, online interaction activities, online support, email, telephone reminders, etc). For example, SHED-IT was an online programme that included educational DVDs, a website and a management app that allowed users to track diet and exercise.28 42 43 Individual personalised exercise plans were created in some programmes such as The Glasgow Football Clubs programme33 while seven programmes offered incentives/paid membership (Gutbusters, FFIT, Aussie FIT, EuroFIT, Hockey FIT, REFIT and POWERPLAY20 25 28 31 32 40 42–47 (online supplemental table S3).

In terms of the length of group sessions, the HAT TRICK, EPL football clubs and FIT programmes offered 90–120 min sessions spread over 12 weeks (n=11). Other programmes included an interaction time of 60–120 min for 6–10 sessions (n=9) while SHED-IT had a non-specified contact time.

Retention/completion rate

Among studies reporting participant retention/completion (online supplemental table S3), a high retention rate (over 80%) was observed in 20 studies. Notably, Glasgow football clubs’ programme for middle-aged men in the West of Scotland had a 100% retention rate.33 Moderate retention rates (around 60%–79%) were seen in seven studies.26 29 34 37 38 44 48 The lowest retention (50%) was seen in a community-based local sport partnership for people at risk of cardiovascular disease and insufficient physical activity.49 In terms of retention in the postprogramme follow-up period, the rate was highest at postintervention and was slightly decreased at future follow-up time points as reported in three studies.31 45 49 For example, a professional football club in Scotland reported a higher retention rate (increment from 90% to 95%) at 12-month follow-up while the rate remained unchanged in the most recent SHED-IT programme between 6 and 12 months (online supplemental table S4).

Programme feasibility and effectiveness

Programme feasibility was reported in 31 quantitative studies consisting of 20 RCTs and 11 non-RCT studies using pre/post analysis approaches (within group) for the treatment group. 15 comparison groups were reported among 11 studies. Of the 20 RCTs, three RCTs and two pragmatic RCTs reported the within group changes for selected outcomes (such as 3 months outcome or weight change) while the programme’s effectiveness was reported in 14 studies using the between group analysis approach (online supplemental table S4).

Mixed evidence for the effectiveness of the programmes (n=14) was reported at 3, 6, 9 and 12 months postintervention. The majority of studies reported beneficial differences in weight (n=9), BMI (n=8), moderate and vigorous physical activity (n=5), sedentary behaviours (n=1) and waist circumference (n=9) at 3 months. For example, the observed reduction in weight ranged between 2.5 kg (95% CI 1.2 to 3.9) and 3.9 kg (95% CI 1.4 to 6.5) at 3 months for those receiving the intervention. A similar trend was observed for the 6-month measures.

Economic evaluation

Five studies reported cost and benefit.20 25 46 50 51 The short-term effectiveness of the intervention on benefit (eg, weight reduction and Quality Adjusted Life years (QALY)) was reported in all studies. For example, the cost of $1315 per additional man achieving a 5% weight loss at 3 months in Aussie FIT46 and the cost of £862–£2228 per additional man achieving and maintaining a 5% weight reduction at 12 months in FFIT20 and EuroFIT25 were estimated. In addition, the effectiveness of EuroFIT lasted only 1 year postintervention. The effect was reported as €5206 per QALY gained50 and did not remain in the longer term, that is, 10 years.

Adverse events

Two studies reported on adverse events, which included a gallbladder removal and hospital admissions with suspected heart attack, ruptured gut and a ruptured Achilles tendon.20 However, only the gallbladder removal and ruptured Achilles tendon were linked to the intervention. In addition, a rate of 5% of musculoskeletal injuries was attributed to an intervention offered by a professional Hockey club in Canada.47

Acceptability, experiences and challenges

Methods of recruitment

Two studies (HAT TRICK and Premier League Health) reported that word of mouth via the host club of a particular sport (eg, football) was the most effective recruitment strategy.52 53 For example, 44% of the participants were recruited using this method in HAT TRICK.52 However, mixed responses were noted among some men regarding the proposition of attending interventions delivered by rivals of clubs that some men supported. While a proportion of fans accepted programmes run by local or rival clubs, the strategy might not work with fans of a specific club. A participant claimed “Yeah, I wouldn’t want to go, if it was at [the Reds], but because it is at [the Blues], it is better”.53 Lower response rates were noted for other recruitment strategies such as radio interviews (24%), social media (16%), print articles (11%) and the HAT TRICK webpage (5%) or via health services pathways (ie, general practitioner doctor referral).52 54

Participant motivations

Six studies reported on participants’ motivations. The most common reason for men to consider weight loss was the perception of improvements in health and fitness.27 55–57 In two studies, motivation to lose weight was seen to be linked to underlying health issues such as type 2 diabetes or being at risk of developing cardiovascular diseases (such as heart attack or stroke).53 57 Another motivation was perceived quality interaction and bonding activity between fathers and their children: “I really enjoyed it. The kids enjoyed it”.37

Factors that attract men to participate

Two studies showed that a gender-sensitive approach encourages men to participate by providing a male-only environment with other men who share similar cultural preferences and with information tailored for men while also having the backing of a reputable organisation (eg, sport club).19 57 The notion of participation in sport and engaging in competition are also perceived as key factors to attract men.27 52 53 56 In addition, the use of sporting contexts can promote a sense of belonging.32 A participant who was a former professional player commented: “I grew up in the hockey rink so just hearing the practice in the background and the sounds and smells of the hockey rink it’s just a comfortable place, so much better than the gym atmosphere”.58

In addition, future opportunities to develop skills and education were also found to be incentives in two studies.27 44 There were clubs that provided men with the chance to study for coaching and sports leadership qualifications. A participant commented “I’ve took my level one and two coaching badges, I played at the Reds last year, scored two goals against all the Reds legends, that was like the perk, you know, plus I got my coaching badges”.53

The appeal of playing sport, engaging in competition and using the club infrastructure (n=4) was found important to men in programmes.52 53 56 58 The convenience and set-up of activities were found important in both work-based interventions and community setting interventions.32 Seaton et al noted the importance of setting up the environment that encourages men to participate.27 This included “installing a basketball hoop and bike rack, continuing to offer fruit for employees, refreshing their existing health incentive programmes, putting in an outdoor shelter and walking paths for employees to use on breaks, and plans to put in a gym when a new building is constructed”.27

Men’s perspectives and experiences of the intervention

10 studies reported the importance of participant’s notion of personal control with or without support along with satisfaction in the delivery method and context, except Tripathee 2020.59 For example, in FFIT, the experience of being in the environment of choice (ie, being with peers who were like-minded) improved positive interaction and enjoyment.19 Similarly, in HAT TRICK, the notion of personal control allowed men to make a small and manageable change.58 It was also reported that participation in the intervention led to better health. For example, a participant commented that “it helps you lose weight and helps you cut down on smoking”.53 Furthermore, participants reported positive changes in health behaviours such as decreased recreational drug use (eg, cannabis and ecstasy), adopting a healthier diet53 and trying new physical activities (badminton, floor hockey, etc).52 The overall positive impact remained postintervention.27

Influence of partners, family and friends on men’s engagement

5 studies reported on the influence of peers, partners and family on men’s engagement. The importance of partner support is emphasised in interventions that include dietary components. Men reported the positive impact of the moral support of a spouse on the success of adopting the intervention and maintaining its effect.59 In addition, in a programme involving father and daughter participation, a father expressed “I’m working during the week and it’s just nice to have that dad-and-daughter time when just for a couple of hours it was just us and I think we’ve really benefited from that”.37

Men, physical activity and supportive digital devices

In one study, men reported that knowledge about healthy diet and physical activities gained during the programme will stay with them throughout their lives and might also have a positive impact on their families.27 In addition, the authors reported digital devices were important in maintaining motivation for physical activity noting that “men were seen wearing their pedometers to track steps long after the first challenge was over”27 while a small-step approach created motivation to make changes that fitted into men’s lifestyle. A participant reported having made better food choices and being willing to accept new things.58

Understanding social interactions within a weight management programme

Four studies reported that male participants value peer support, team spirit, the opportunities to speak to similar men and the camaraderie that may gradually build-up via interactions while undertaking a gender-sensitive programme.8 16 22 40 43 Most gender-sensitive programmes (n=9) incorporated a group delivery format to increase interaction among participants and to build camaraderie. Notably, in HDHK, one dad commented “I enjoyed the group-based elements … it allowed people to bounce off, talk about—and also the blokes, a little bit of competitive edge, especially when the weight round was coming. So I think it benefited me and I preferred the group format rather than just individually between me and my children”.37 Friendship among men has been shown to be strongly linked to the adherence to weight-loss programmes.56 The interaction between ‘peers’ plays an important role in FFIT, MOM and HAT TRICK. In the groups, members trust and encourage each other to talk about topics they would normally consider ‘feminine’, such as diet and weight loss.19 32 52

Challenges to successful engagement with interventions

A total of five articles documented the challenges faced by participants.20 27 32 54 55 For example, some men were not interested in healthy eating and physical activity.27 Some coaches reported insufficient time to understand and prepare detailed instructions for each session.54 In a workplace setting, Seaton et al reported intermittent difficulties due to other workplace priorities such as increased demand in productivity during busy periods.27 In addition, fear of getting back to old habits was reported in Blunt et al due to factors that might prevent men from being physically active.55 These included medical conditions, injury and weather. A participant expressed “I would say the biggest challenge that I faced is winter. I think it’s tough to move in the winter and that tends to pack on weight”. Second, technical problems often arose for older participants (eg, problems with using apps)27 55 while tracking devices such as pedometers are not suitable to record some activities (eg, swimming).27

Finally, time and location might prevent men from participating in the programmes. For example, the convenience of the location, availability of workout partners and time of operation of the participating gym centres were the barriers for men to maximise the benefits of the programme. One participant commented “I could have made time, but I would have if I had someone near me that said, hey I’m going. I could have made time, but like I said, I was by myself, so I was like, I’ll just run around my complex at home. So connecting with all the groups, finding out who lives near you. I could have linked up with some of you [men in the focus group] as soon as my group ended; I just didn’t know anyone that lived near me”.20 32 55

Areas for improvement

One study reported that feedback from coaches and participants suggested that having more sessions or longer sessions might be beneficial in building up trust, interactions, connection, team relationships and having more time to elaborate on the detailed instructions and make adjustments to meet the needs of participants.52 Participants in two further studies also stated that sessions could be extended to enhance additional activities, such as goal setting and competition between groups.32 53

In relation to language use and appropriateness of material, feedback suggested that external speakers (ie, a nurse specialist) might need to be mindful of the language used. Pringle et al emphasised the importance of chosen language used by intervention deliverers towards participants: the “language he was using was not right. It was like the f-word every time, for me when you’re coming to speak to people, and you don’t know where they are coming from; you have to really respect people”. The value of more personalised messages was also expressed by men who participated in group competitions due to different levels of personal skills, needs and different preferences.53 55 In addition, programmes such as HDHK suggested that scheduling of programmes outside of winter could be beneficial as was noted in participants’ feedback.52

Discussion

This review set out to provide an overview of gender-sensitive community-based weight programmes to address men’s overweight and obesity. The findings suggest the field is evolving rapidly and that gender-sensitive approaches are highly adaptable to different settings. There is evidence that these programmes are effective in achieving sustained weight loss in men.20 25 47 51 60 Notably, many of the programmes have included an RCT design and this strengthens evidence that these programmes could be effective in achieving their goals.20 25 28 29 35 36 40 42 44 46 47 51 61 62 However, ascertaining the effectiveness of the gender-sensitive approach will require a systematic review of evidence. Most importantly, a gender-sensitive approach that values social interaction (ie, peer support, team spirit and camaraderie) and cultural preferences (ie, traditional roles and expectations) has been shown to overcome the challenge of engaging men in weight-loss programmes while economic evaluations demonstrated short-term cost-effectiveness in cost and benefit.

One important aspect of the findings is that the review did not identify studies for diverse subpopulations of men such as men who identify as gay and bisexual, immigrant men, men from Indigenous communities and neurodiverse men. Therefore, there appears to be a gap with regard to evidence on gender-sensitive programmes that focus on these subpopulations.

In seeking to understand why gender-sensitive programmes may be more likely to engage men, Bunn et al identify the importance of cultural commonality in generating shared experiences that allow men to negotiate and adopt new masculine health behaviours.19 In the context of gender-sensitive interventions situated in sports clubs, a key aspect of this cultural commonality is a shared symbolic commitment to the sporting club and to being with men who they perceive as similar.19 Many programmes appear to have drawn on these key aspects in design and adapted these elements to different contexts.

In addition, theoretical literature argues group-based dynamics are an important element to engage men in health-related activities in gender-sensitive programmes.19 Although previous studies in mental health research have shown men prefer individual approaches in managing issues,63 the findings of this review demonstrate that a group environment in an appropriate setting can produce a dynamic and motivating effect.27 55–57

One important aspect of gender-sensitive approaches is the focus on positive aspects of men’s gender roles and ideals. While gender theory has contributed to a more sophisticated understanding of the factors that shape men’s health patterns,64 65 some authors have argued that a focus within the men’s health discourse on negative aspects of men’s gender roles has not provided a good starting point for undertaking change.66 67 Focusing on a strength-based approach and advocating for alternative masculinities may offer a stronger basis for more effective men’s health programmes.66

The findings have important implications. The first is to suggest that the application of gender-sensitive weight-loss programmes holds potential for addressing men’s overweight and obesity. However, further studies of the longer-term impacts are required in broader populations of men, including future studies with longer follow-up and evaluation as well as a systematic review. A further implication is that, given the demonstrated potential of the intervention design, gender-sensitive interventions may be applicable to other men’s health issues and also to health issues in other gender groups.

This review is strengthened by the utilisation of a comprehensive search strategy that included both quantitative, qualitative and mixed-methods findings that represent the most up-to-date evidence on this topic. However, a limitation is that the review did not specifically search for literature related to subpopulations of men. The review also did not capture studies published in languages other than English.

Conclusion

There are increasing calls to address men’s health challenges through gender-sensitive approaches.68 69 The development of gender-sensitive programmes offers the potential to better engage men in community-based weight-loss programmes. However, more evidence will be required to ascertain whether the approach is effective in different settings and with different groups of men.

Data availability statement

All data relevant to the study are included in the article or uploaded as supplementary information.

Ethics statements

Patient consent for publication

Ethics approval

Not applicable.

Acknowledgments

We acknowledge the assistance of Deakin University Librarian Rachel West in the development of the search strategy.

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