Nearly 3 in 4 Black men are at an increased risk for chronic diseases such as diabetes, hypertension, and some cancers due to excess weight,1–5 and more than a third (38%) are classified as obese.6 Enrollment in behavioral weight loss interventions is lower among Black men compared with White men, and when enrolled, they lose less weight.7,8 Given Black men’s high rates of overweight and obesity, low participation rates in weight loss studies, and suboptimal weight loss outcomes, some have questioned if they may benefit from culturally adapted weight loss programs.9,10 Effective cultural adaptations to standard interventions have included the delivery of services in the community rather than clinical settings, communicating using the target population’s native language, and including cultural values in recruitment and intervention strategies.11–14 Involving family members as a cultural adaptation is appropriate because of the strong sense of communalism and cultural associations of the Black family in Black men’s health.
In the family unit, individuals are interdependent, which can translate into social infrastructure and support. A review on the role of social support in diabetes management among Blacks found that they rely more heavily than whites on informal social networks (eg, church and family) and that, in this population, social support has been associated with improved diabetes outcomes.15 Family members may be more cognizant of an individual’s health behaviors to include facilitators and barriers to weight management and may be uniquely positioned to challenge maladaptive behaviors and encourage and support adaptive strategies for more favorable outcomes.
Including family members in weight management trials by recruiting parent–child dyads/triads or romantic dyads has yielded inconsistent results,16 possibly because family involvement does not translate to the quality of support being provided. Trials using these stakeholders as support agents must focus on training and systematically engaging family toward the outcomes that are desired rather than assuming that they are always positive.
The theoretical foundation and skills building for such interventions have historically focused on intrapersonal factors such as stimulus control, self-reinforcement, and self-regulation.17–21 However, this approach is inconsistent with the Academy of Nutrition and Dietetics recommendation that weight loss interventions incorporate strategies addressing multiple levels of the socioecological model to increase effectiveness. A review of weight loss interventions for men contained only 1 study using a dyad- or couples-based approach.22 Trief et al23 used interdependence theory, a dyad-based theory, as the foundation for a couples-based diabetes mellitus management pilot program and found that promoting collaborative communication between the partners yielded meaningful clinical improvements in medical outcomes. A separate couples-based intervention for Black adults with type 2 diabetes successfully targeted similar interpersonal behaviors. However, and consistent with many studies on Black populations, the majority, 81%, of the sample was female.14 Employing dyad-based theoretical frameworks and skills building presents a viable option for effectively intervening on multiple levels.
Individuals in romantic relationships influence each other’s health practices,24 but the ideal composition of effective dyadic or couples-based weight loss interventions is unknown. Longitudinal studies have investigated associations between marital status and health behaviors among men.25 Couple-based interventions addressing relationship functioning for health outcomes have had more success than interventions not targeting relationship dynamics.26 Compared with targeting individuals to change health behaviors, it may be more advantageous to take advantage of the individual and mutual influence represented by couples, and including efforts to improve or accommodate couples’ functioning may be the most important and historically neglected agent of change in couples-based interventions. However, it is unclear whether such interventions may impact relationship dynamics. Although partner involvement may curtail health-compromising behaviors or encourage health-promoting behaviors, there is a potential for psychological distress.27
The Together Eating & Activity Matters (TEAM) study was a randomized controlled pilot designed to test the efficacy of partner involvement in weight loss compared with a standard behavioral weight loss treatment, specifically for Black men. In the intervention group, Black men participated with their wives or cohabitating girlfriends, and in the control group, Black men participated alone. Using the interdependence theory and communal coping, the intervention was designed to produce clinically significant weight loss by improving relationship functioning (ie, dynamics). Improvements in relationship functioning (eg, communication, cohesion) were predicted to enhance support provide and individual self-efficacy and regulation for weight loss and associated behaviors.
To determine the effects of the couples-based weight management intervention on family and couple functioning, social support, self-regulation, and self-efficacy, we analyzed data from the TEAM study. The results of a randomized pilot with 40 couples have been reported.28
Briefly, the partner intervention produced weight loss of 4.7 ± 8.04 kg at 3 months compared with 3.4 ± 5.9 kg in the standard intervention. Beyond the intervention’s effect on weight, this research also aimed to examine the association of the support variables and changes in weight. Figure 1 depicts the conceptual framework used to guide the development of the intervention and this analysis. The TEAM intervention was hypothesized to improve couples’ functioning, thereby improving the quality and quantity of social support provided to Black men for changing diet and activity behaviors to facilitate weight loss.
Materials and methods
Approval of the procedures and ethical considerations for this study was provided by Institutional Review Board at the University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, June 2015.
Black men and their partners were recruited through passive and active strategies. Eligibility criteria included (1) self-identification as a Black male, (2) cohabitation with self-identified Black girlfriend or wife, (3) aged 18−65 at time of enrollment, (4) body mass index of 25−45 kg/m2, and (5) access to the internet and a personal email at least twice a week. Exclusion criteria included (1) current enrollment in a weight loss program, (2) self-reported weight loss of 10 lbs or more in the last 6 months, (3) undergoing cancer treatment, (4) a type 1 diabetes diagnosis, and (5) taking medication that affect body weight (eg, insulin, chronic steroid use). Written and electronic consent was provided by all participants. Recruitment and eligibility were described in detail previously.28
The TEAM intervention used a cohabiting partner as a source of social support to promote weight loss and healthy behaviors among Black men. Detailed methods have been published.28 Briefly, participants were randomized to 1 of 2 behavioral weight loss programs: a spousal support-enhanced intervention or standard behavioral weight loss comparison group. Figure 2 depicts recruitment, enrollment, randomization allocation, and follow-up assessments. The intervention was based on the Social Cognitive Theory and the theories of Interdependence and Communal Coping.29 Strategies addressing transformation of motivation (eg, where an individual’s behavior and/or motivation shifts from self-centered to a prorelationship orientation) and communal coping (eg, the shared acknowledgment of a health concern by a couple and the joint effort to address and/or manage the threat) were incorporated in the intervention components for the enhanced group. Each study arm completed its intervention over 12 weeks. All participants received a standard behavioral weight loss program that included calorie reduction and physical activity prescriptions, individualized weekly feedback, and a digital scale with recommendations for daily weighing.30–32 Participants were encouraged to monitor diet and activity behaviors using the MyFitnessPal app and website to build self-efficacy and practice self-regulation. Participants in each arm also attended group sessions and received weekly emailed behavioral lessons. In addition, the enhanced arm attended group sessions with their partner along with a single Couples Skills Training session focused on improving commitment, communication, and social support. Example topics in the enhanced and standard weight loss groups included navigating high-risk situations, learning to incorporate more physical activity and integrating healthy eating into lifestyle, and recognizing cues for unhealthy behaviors. A portion of each session focused on goal setting and scenario-based problem solving. Homework activities were designed to build self-efficacy and practice skill building. In the enhanced groups, group session activities were completed as couples and at-home activities targeted increasing collective efficacy, improving collaborative problem solving, enhancing personal risk perception, and exploring coping strategies (eg, proactive, anticipatory, preventive, avoidance, support seeking). Participants were weighed in person and completed online questionnaires at baseline and 12 weeks. The study protocol was approved by the Institutional Review Board at the University of North Carolina at Chapel Hill.
As reported previously,28 we gathered demographic information and data regarding weight, diet, and physical activity from participants. The following constitute the primary measures for this study, administered as 1 questionnaire at baseline and at 12 weeks.
Scales from the Family Context questionnaire used in the Weight Loss Maintenance Trial33 were used to assess couple dynamics. Themes assessed through the questionnaire’s subscales (family communication, family cohesion, emotional involvement, and perceived criticism) are consistent with the constructs (eg, communication, relationship functioning) necessary to transform motivation and increase communal coping.
Family communication was assessed with the communication subscale (6 items; Cronbach’s α = 0.54) of the McMaster Family Assessment Device.34 Communication was defined as the exchange of information among family members. Items focused on whether verbal messages were clear and direct for the intended recipient. Reponses ranged from “strongly agree” to “strongly disagree.” Higher scores represent unhealthy communication.
The cohesion subscale (10 items; Cronbach’s α = 0.86) of the Family Adaptability and Cohesion Evaluation Scale III35 measured the emotional bonding family members have with one another. Items like “Family members ask each other for help” were rated on a 5-point Likert scale from “almost never” to “almost always.”
The family emotional involvement (7 items; Cronbach’s α = 0.71) and perceived criticism (7 items; Cronbach’s α = 0.81) subscales of the Family Emotional Involvement and Criticism Scale36 (Cronbach’s α = 0.54) rate items like “I am upset if anyone else in my family was upset” on a 5-point Likert scale, as above.
Collaborative problem solving
The Family Problem-Solving Communication Index (10 items; Cronbach’s α = 0.26)37 was used to measure the specific communication style that families use to manage and solve problems and conflicts in various types of stressful situations. Consisting of 2 subscales, affirmatory communication (Cronbach’s α = 0.81) and incendiary communication (Cronbach’s α=0.54), the response options were “false,” “mostly false,” “mostly true,” and “true.”
Social Support Effectiveness Survey (25 items; Cronbach’s α = 0.81)38 measured partner social support effectiveness. The measure included items assessing the quantity and quality (eg, “To what extent did you wish this person’s advice or information had been different somehow—for instance, a different type of help, or offered in a different way or at a different time?”) on a rating scale ranging from “not at all” to “extremely” for 3 types of support (eg, emotional, informational, and instrumental). The measure also assessed negative byproducts of support provided (eg, feelings of guilt or indebtedness) using Yes/No options. Total scores ranged from 0 to 80, with higher scores indicating more effective support.
The Social Support and Eating Habits Survey (10 items; Cronbach’s α = 0.72)39 measured social support specific to healthy eating. Subscales assessed encouragement for eating behaviors from partners (eg, “Encouraged me not to eat ‘unhealthy food’ when I am tempted”) (Cronbach’s α = 0.90) and discouragement for eating behaviors from partners (eg, “Brought home foods I am trying not to eat”) (Cronbach’s α = 0.74). The items were rated on a scale of “none” to “very often.” Total scores ranged from 5 to 50, with higher scores indicating more social support for eating behaviors.
The exercise participation subscale of the Social Support and Exercise Survey (10 items; Cronbach’s α = 0.90)39 measured social support specific to exercise behaviors. The subscale assessed the level of support for exercise from partners. Subscale example items included “Exercised with me” and “Criticized or made fun of me for exercising.” Total scores ranged from 5 to 50, with higher scores indicating more social support for exercise participation behaviors.
The Eating Behavior Inventory (20 items)40,41 measured the adoption of eating behaviors associated with weight loss (eg, monitoring quantity eaten, frequency of weighing, shopping from a list) and has been shown to be sensitive to behavioral interventions. More specifically, the Eating Behavior Inventory measured self-regulation behaviors. These items are rated on a 5-point frequency scale from “never or hardly ever” to “always or almost always.” Scores range from 26 to 130.
The Weight Efficacy Life-Style Questionnaire (20 items; Cronbach’s α = 0.93)41 measured individual’s perceptions of their ability to control their weight related to eating patterns and attitudes at baseline and postintervention (eg, self-efficacy). Five situational factors, Negative Emotions, Availability, Social Pressure, Physical Discomfort, and Positive Activities, were rated with a 10-point scale ranging from 0 (not confident) to 9 (very confident), with higher scores indicating greater self-efficacy. Scale scores are calculated by adding the 4 items in each scale and a total Weight Efficacy Life-Style Questionnaire score by adding all items.
The confidence subscale of the Patient-centered Assessment and Counseling for Exercise Adult Diet and Physical Activity Measure (6 items; Cronbach’s α = 0.87)42 measured confidence in participating in regular exercise or physical activity in different situations (eg, “How confident are you that you would participate in regular exercise or physical activity: When I am tired?”). Items were rated on a scale from 1 (“not at all confident”) to 6 (“extremely confident”).
Selected baseline characteristics were compared between the standard treatment and enhanced group using independent t tests for continuous variables and chi-square tests for categorical variables. Change scores for psychosocial and family functioning variables were calculated by subtracting the values at baseline from values at 12 weeks. Between-group differences were compared using simple linear regression and effect sizes. Lastly, we evaluated the associations between changes in psychosocial factors in relation to weight loss using Pearson’s correlation.
We were particularly attentive to moderate effect sizes (d > 0.4) because they represent meaningful differences between groups. Cohen classifies a medium effect as d = 0.5 and d = 0.2 as a small but not trivial effect.43 We also were attentive to P < 0.20 to indicate important relationships to consider for future investigations because this value corresponds with the moderate effect value selected.44 We adjusted for baseline variables in the regression models because of differences in groups at baseline and to calculate more precise change scores. When appropriate, we estimated internal consistency using Cronbach’s α for each measure and subscale using study data. We used SAS software (Version 9.4; SAS Institute, Cary, NC) for all analyses.
Results and discussion
Table 1 shows baseline characteristics by study group, described previously.28 There were significant baseline differences in some social support measures, emotional involvement, and self-efficacy for physical activity between the enhanced and standard groups. At 12 weeks, 100% of participants were weighed and 87.5% (35) completed the Paffenbarger Physical Activity Questionnaire and 24-hour dietary recalls. All 40 male participants (100%) completed the online baseline questionnaire and 38 (95%) completed the postintervention questionnaire after 12 weeks; the remaining 2 participants were not able to complete the online questionnaire within the assessment window.
Table 2 presents family functioning changes over time. When adjusting for baseline values, differences between the enhanced and standard group in communication, incendiary communication, family cohesion, and emotional involvement yielded moderate effect sizes. However, these changes were not in the expected direction among participants in the enhanced group when compared with participants in the standard group. Communication among the enhanced group decreased (β = −0.40, t  = −1.93, P = 0.06, d = 0.64) compared with the standard group. Incendiary communication, however, increased in the enhanced group (β = −1.07, t  = −1.33, P = 0.19, d = 0.44) compared with the standard group. Similarly, in the enhanced group, family cohesion (β = 4.10, t  = 2.20, P = 0.03, d = 0.76) and emotional involvement (β = 2.81, t  = 2.17, P = 0.04, d = 0.77) decreased over 12 weeks, whereas these variables did not change in the standard group. There were no differences between groups in the other family functioning variables.
Social support, self-regulation, and self-efficacy
Table 2 also presents changes in social support, self-regulation, and self-efficacy. There were no differences between groups in any of these dimensions.
Associations between social support and weight
Table 3 presents a matrix of Pearson Correlation Coefficients for changes of social support and weight loss. Weight loss was associated with social support effectiveness (r = −0.44, d = 0.008), as well as several of its subscales including task support effectiveness (r = −0.32, P = 0.05), emotional support effectiveness (r = 0.25, P = 0.14), and negative effects of social support (r = −0.34, P = 0.04), as expected. Social support for eating discouragement was associated with weight loss (r = −0.32, P = 0.06). In contrast, informational support effectiveness was not related to weight loss (r = −0.18, P = 0.28).
The primary purpose of this article was to examine the effects of a spousal support-enhanced behavioral weight loss program on psychosocial outcomes in Black men. Specifically, we explored the relationships between the intervention and aspects of family functioning (eg, communication, problem-solving communication, cohesion, perceived criticism, and emotional involvement), social support (eg, social support effectiveness and social support for eating and exercise), self-efficacy for eating and exercise, and self-regulation behaviors for weight loss among Black men. In this intervention, couples attended groups together and developed and refined communications skills. Compared with a standard behavioral weight loss intervention, the spousal support-enhanced behavioral weight loss program produced greater negative effects on aspects of family functioning such as family communication, cohesion, and emotional involvement compared with a standard treatment where men attended weight loss groups without their spouse.
We found that Black men who participated with their partners were more likely to report worsening in their functioning with their partner compared with Black men who participated alone. For example, family cohesion and emotional involvement decreased in the enhanced group. Incendiary communication, which is characterized by inflaming an already bad situation, increased in the enhanced group. Thus, although this study showed that participating with a partner produced an additional 1 kg of weight loss in the men (d = 0.18) and 2 kg in their partners compared with the standard treatment that did not include components targeting couple relationship functioning, the enhanced intervention appeared to decrease couple functioning.
In retrospect, the shift to unhealthier functioning, however, is perhaps understandable, considering the potential psychological negative byproducts of weight loss, such as anxiety and distress. Alternatively, we may have simply documented the process of individual therapeutic change where interpersonal relationships are shifted, and negative communications increase before a target moving in a more positive and expected direction. The interpersonal dynamic within an intimate family structure associated with weight loss and change in Black male family dynamics may not always be positive or linear. Discussions on changes to eating habits and kinetic activities within a given day may be continuous, strained, and argumentative resulting in mood states that vary in intensity and direction for both the male and his support. Assumptions of linearity of change and only positive clinical outcomes associated with the process of weight loss are overestimated and potentially ecologically invalid in black families.
We believe that we simply documented the path of change in the family dynamic for Black men who were in established relationships where health behaviors could have been previously ignored or not aggressively reinforced and were now being challenged to engage in adaptive weight loss behaviors. We posit that such dynamics may occur in all couples-based interventions as part of the sequence of adaptive change and we encourage others to reevaluate their findings in this context when data are available or replicate our findings in new study protocols.
Engaging in the behaviors necessary to produce initial weight loss may result in more arguments or contentious interaction within romantic relationships. One study found an association between increases in depressive symptoms and increases in eating restraints at 10 kg of weight loss in a sample of men who were obese.45 The nature of interdependence can lead to negative interactions, whether reciprocated or not.46 Weight loss is a sensitive topic and requires consistent focus on changing diet and activity behaviors. Partners who cohabitate may witness their significant other’s failure to make the necessary changes to facilitate weight loss. In such circumstances, pointing out a partner’s behavior may not always be welcomed.
Given the limited time across which variables were studied, the durability of the intervention’s effects is unknown. An increase in incendiary communication may be necessary, and even welcomed, because it may signal an increase in or a shift toward more open and honest communications about health. It has been suggested that negative communication can help partners resolve problems and lead to long-term greater relationship satisfaction when training is provided to couples on conflict resolution strategies. Wives’ “anger” can motivate “partners to bring about desired change.”47–49 Our results suggest that Black men engaged in collaborative problem solving may benefit initially via the agent of negative communication. If incendiary communication resulted in a more negative influence, it may be that the single communication skills training provided at the beginning of the 12-week program was not sufficient to ensure that when partners challenge each other to change behaviors, they do so using open and honest dialogue that reduces potential for conflict. Alternatively, alerting couples at the beginning of interventions to the possibility of increased negative communications as part of normal therapeutic change and preparing them with skills may be sufficient.
Despite the decline in cohesion in the enhanced group, the eventual measure remained within the range of “connected” on the scale being used (the spectrum ranging from disengaged [10.00–26.81] to enmeshed [39.20−50.00]). In fact, “connected” family cohesion suggests a balance of togetherness and separateness, which could represent optimal, or “balanced,” family functioning when assessed as the curvilinear relationship proposed by Olsen. Functioning at either extreme category (eg, disengaged or enmeshed) may predict long-term problems.50 The negative shift toward “separated” cohesion suggest these Black couples enrolled with optimal functioning at baseline. In other research, family cohesion has been found to be a predictor of successful weight loss among Blacks.33 Preserving the existing cohesion among Blacks or identifying strategies to shift couples to “balanced” functioning would be the next step in couples-based weight loss program.
Cohesion has also been found to be associated with emotional involvement and social support51; thus, the apparent decline in emotional involvement in the enhanced group was expected due to the “negative” shift in cohesion in the enhanced group. It is unclear whether high levels of emotional involvement, a dimension of the Expressed Emotion Theory, is important for successful weight loss from the perspective of the individual attempting to lose weight. As with other factors already discussed, emotional involvement may not be entirely beneficial, particularly when it becomes overinvolvement.51 Research has shown that families with high levels of expressed emotion can be more critical and intrusive in face-to-face interaction.51 The decline in emotional involvement may represent a shift to more “balanced” functioning. A qualitative analysis assessing the participants’ experiences of observed shifts in cohesion and emotional involvement would help with the interpretation of these results.
The conceptual framework for the intervention targeted improvements in family functioning as a means to achieve greater enacted social support and social support effectiveness. There were no between-group differences in these aspects of social support. Lack of improvement in family functioning, as described above, may provide 1 explanation for the lack of improvement in social support measures. It may also be that couples who decide to enroll in a weight loss intervention as a team are already fairly high functioning and supportive compared with couples who would not consider enrolling together; these couples may, in general, provide social support relatively regularly and effectively. TEAM participants were screened for marital satisfaction. Another potential explanation given the potential that we enrolled mainly high-functioning couples is that the approach used here, to improve family functioning as a means to increase support, may be more effective for men with low social support at baseline.
Though the intervention did not result in the desired differential changes in social support overall, the importance of social support in health behavior change is well documented52 and identifying strategies to enhance social support and the way it is delivered is important. This investigation attempted to distinguish which types of effective support are important, using the Social Support Effectiveness questionnaire. To our knowledge, this is the first usage of this measure in a weight management trial. As individuals provide more than 1 type of support at a time, distinguishing between the contribution of each type of support has been difficult.53 Objective measures of support are needed in combination with the currently used measures. In this study, most types of effective social support, except for informational support from partners, were associated with weight loss. This may suggest that information does not need to be provided “skillfully,” but simply provided. Informational support is also the dominate form of support in behavioral interventions. Therefore, informational support from a partner may not be as important.
However, this study had several minor limitations. First, this study used novel, though untested, measures for theoretical constructs of communal coping and transformation of motivation because, to our knowledge, published measures were unavailable. Previously, researchers have used in-depth interviews to access transformation of motivation and communal coping between partners. Therefore, our study results cannot be directly compared with the results of other studies. Second, we did not include qualitative methods to investigate the shifts in family functioning. A short semistructured interview pre- and postintervention would provide insight to the shift in family functioning in both groups. Additionally, all measures were self-report. There is a potential for recall bias and social desirability in reporting dietary and physical activity behaviors and family functioning. Lastly, our sample size may not have provided the statistical power to see other significant results if they existed. In this context, replication of our findings is required to establish the reliability of our findings.
Our study had several strengths. The data for this analysis were from a randomized controlled pilot study, with multiple measurements, allowing us to infer causal relationships between changes in theoretical constructs and the intervention. Also, we included multiple measures of social support to assess support from different dimensions. The study and results add to the paucity of research literature evaluating behavioral and theoretical constructs among Black men attempting weight loss.
This study adds to the limited literature on the psychosocial factors influenced by partner involvement in weight loss interventions. More importantly, to our knowledge, it is the first evaluation of family functioning measures in weight loss among a study sample where the index partners were all Black men. The changes observed resulted in a 1% greater increase in weight loss among participants in who participated with their partner. Together these findings suggest future research should (1) investigate strategies to improve or preserve those aspects of family/couple functioning associated with weight loss, such as communication and cohesion; (2) assess the long-term impact of the intervention on family functioning, particularly among a sample with varied functioning at baseline; and (3) use a mixed-method approach to assess shifts in family functioning. A logical next step may be to try to anticipate and address the negative effects of partner involvement with a more intensive intervention.
We are indebted to the Together Eating & Activity Matters (TEAM) Group members (listed alphabetically) Brandon Bishop; Molly Diamond, MPH; Christian Eller; Karen Hatley, MPH; Laurie Hursting; Jovia Ochieng; Elissa Scherer; and Chris Wiesen, who provided statistical consultation from the Odum Institute at the University of North Carolina at Chapel Hill. We thank our community organizations and stakeholders who provided digital weight scales and fitness passes and the participants who made this study possible.
The authors have no financial interest to declare in relation to the content of this article.
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