Social support is important to achieve beneficial changes in risk factors for disease, such as overweight and obesity. This paper presents the theoretical and practical framework for social support, and the mechanisms by which social support affects body weight. The theoretical and practical framework is supported with a literature review addressing studies involving a social support intervention for weight loss and weight loss maintenance.
A major aspect in social support research and practice is the distinction between structural and functional support. Structural support refers to the availability of potential support-givers, while functional support refers to the perception of support. Interventions often affect structural support, for example, through peer groups, yet functional support shows a stronger correlation with health. Although positive correlations between social support and health have been shown, social support may also counteract health behaviour change.
Most interventions discussed in this review showed positive health outcomes. Surprisingly, social support was clearly defined on a practical level in hardly any studies, and social support was assessed as an outcome variable in even fewer studies. Future social support intervention research would benefit from clear definitions of social support, a clear description of the intended mechanism of action and the actual intervention, and the inclusion of perceived social support as a study outcome.
Overweight and obesity increase the risk of morbidity from hypertension, dyslipidaemia, type II diabetes, coronary heart disease, stroke, gall bladder disease, osteoarthritis, sleep apnea and respiratory problems, and endometrial, breast, prostate and colon cancers. Higher body weights are also associated with increases in all-cause mortality (NIH, 1998). Weight loss and the prevention of weight gain in defined groups or in the general population are therefore important. This stresses the need for interventions aimed at improving dietary and physical activity patterns. While information, support and technical advice from health workers can be a key factor in behaviour change, most of the dynamics of behaviour change take place in patients’ private and work settings. In these situations, social support from people's natural environment plays an important role. In this paper we will start by discussing the theoretical and practical framework behind social support, and the mechanisms by which social support affects lifestyle and health. The effectiveness of lifestyle-focused social support interventions in weight management will be addressed in a systematic review of the literature. We conclude with reflections on the incorporation of social support in lifestyle interventions.
Structural and functional social support
The term social support is used for a broad range of concepts and partly overlapping functions, such as emotional, instrumental, informational, and appraisal support (Cohen & Wills, 1985; Vaux, 1988; Antonucci & Johnson, 1994; Cohen et al, 1994; Langford et al, 1997). A major distinction is made between structural and functional support.
It is the availability of significant others (eg spouses, family members, friends, co-workers, social, and religious groups) irrespective of the actual exchange of support. Structural support is also referred to as social integration (Cohen et al, 2000).
By contrast, is a subjective measure of the perception of support, depending on individual characteristics and expectations (Yopp Cohen, 1988; Connell & D’Augelli, 1990). The perception of support is strongly influenced by personal characteristics (Liem & Liem, 1978; Cohen & Wills, 1985; Lakey et al, 1996; Lakey & Cohen, 2000). Therefore, structural and functional support is not necessarily highly correlated. As perceived, social support has been shown to be stronger correlated with well-being than received support (Wethington & Kessler, 1986), interventions should be focused on increasing functional support rather than structural support. In practice, however, intervention opportunities on the structural support level by adding health professionals or peers seem more feasible than changing people's perception of support (functional support).
Sources for social support
Family members, friends, colleagues, and (church) communities are part of patients’ natural support network and can play a role in the provision of social support. Involving natural support resources in intervention programs is valued by patients and increases program effectiveness, but negative consequences are also reported (Hagen, 1974; Tattersall et al, 1985; Black et al, 1990; Hart et al, 1990; Parham, 1993; Burke et al, 1999). Bringing new sources of support such as peers into action may be helpful when social support from patients’ natural networks is insufficient (Helgeson & Gottlieb, 2000). This may not only lead to improved health of the patient but also of the support giver, for example, because providing support makes them feel good about themselves (Riessman, 1965; Hupcey, 1998; Schwartz & Sendor, 1999). This is referred to as the helper-therapy principle (Helgeson & Gottlieb, 2000).
It has been suggested that social support from health professionals may have a limited effect in comparison to support from patients’ natural support networks. This is largely due to the nonreciprocal relationship between patients and health professionals. A similar nonreciprocal situation is present when trained peers receive financial rewards or when worksite based programs involve supervisors or managers for support (Hupcey & Morse, 1997; Hupcey, 1998). Zablocki (1998), however, showed with anecdotal evidence from various worksites that worksite weight management programs supported by employers can be very successful. Evidence for the success of commercial self-help groups such as the Weight Watchers is also predominantly anecdotal. One of the few studies showed no effect on weight loss (Djuric et al, 2002). The proliferation of self-help groups, however, indicates the public's belief in their effectiveness.
Social support and health
Cross-sectional studies have related social support to health, and social support has also been shown to be important in achieving and maintaining health behaviour change (Berkman & Syme, 1979; House et al, 1988; Amick & Ockene, 1994). Controlling for known determinants of morbidity and mortality, people with low social support levels had a relative risk ratio for mortality of approximately 2.5 (Berkman & Syme, 1979; House et al, 1988). Unfortunately, the cross-sectional nature of much of the research relating socials support to health does not allow for causal inferences. Perhaps, healthy individuals are able to have more rewarding social interactions than their less healthy counterparts. It is also possible that social support results in improved health outcomes or that an unknown factor positively affects both social support and health (Cohen & Wills, 1985).
Lakey and Cohen (2000) provided an extensive overview of the different models explaining the effects of social support on health. One major distinction is the difference between indirect and direct models. In indirect models, social support influences the occurrence of stressful events, the appraisal of stressors and individuals’ responses to stressors. The latter has been suggested to be a result of social support's ability to suppress the production of the stress hormone cortisol (Heinrichs et al, 2003). In indirect models (also referred to as stress-buffering models), social support would only be protective in the presence of stressful conditions (Amick & Ockene, 1994; Cohen et al, 2000). In direct models, by contrast, social support affects psychological and physical well-being, irrespective of the stress levels of the individual. Social support may trigger behaviour change by providing information about diet or exercise, by providing reassurance, or by increasing compliance to treatment (Amick & Ockene, 1994; Bovbjerg et al, 1995; Cohen et al, 2000).
Notably, besides being positively correlated with health, social support can also counteract health behaviour changes (Fleury, 1993; Amick & Ockene, 1994). Peer smoking, for example, may negatively affect the success rate of patients’ quitting attempts or people may (unknowingly) give false or incomplete informational support (Kelsey et al, 1997; Helgeson & Gottlieb, 2000). Finally, social support may counter the state of denial patients had been in to protect themselves from psychosocial effects of their illness.
Literature search strategy: social support in life style-focused weight management intervention trials
To identify papers describing social support intervention studies, the Medline, CINAHL, ClinPSYC, PsycINFO, ACP Journal Club, and Cochrane databases were searched in cooperation with reference librarians. Combinations of the following keywords were used: diet, nutrition, weight loss, (physical) exercise, (physical) activity, social support, functional support, structural support, social network, peer group, self help group, group education, and patient education. Only publications between 1970 and 2003 were included. This yielded over 6050 titles that were reviewed for relevance. Reference lists of the papers were also screened for relevant publications. In this initial step, papers addressing health issues other than adult obesity, such as breast-feeding practices and cancer were excluded. Over 570 abstracts were reviewed, and over 210 papers were read. Papers were included when meeting the following criteria:
randomized controlled trials allowing for evaluation of the effectiveness of the social support component;
adult and older-aged participants;
social support provided through written, face-to-face, telephone, or computer-based interaction; studies involving pets for the provision of social support were excluded. Studies looking at group-based interventions without a specific mentioning of social support were also excluded;
effects measured in terms of body weight.
Over the years, a number of intervention studies involving social support have been conducted. Table 1 gives an overview of the designs and outcomes of 10 lifestyle focused weight management intervention studies that were not addressed in earlier reviews by Black et al (1990) and Kelsey et al (1997) on dietary change and weight loss.
The baseline health characteristics of participants varied between studies. Some studies were conducted with extremely overweight participants, others with breast cancer survivors, or seemingly healthy individuals. In most studies, participants were recruited by means of newspaper advertisements, or patients who were already attending a clinic were asked to participate in research projects. This suggests highly motivated participants and leaves questions about the applicability for the population at large. The interventions varied from 4 weeks to 1 y and follow-ups ranged from 10 weeks to 3 y after the intervention. We found no apparent difference in effectiveness between shorter and longer interventions.
Attrition in the studies ranged from 0 to 56%. A previous review of 16 group counseling studies found an average attrition rate of 35% (Foreyt et al, 1981), and an overview of commercial and self-help groups reported as much as 80% (Rosenblatt, 1988). The demanding nature or duration of some interventions may help explain the high attrition rates. Wing and Jeffery (1999) found considerable lower numbers of dropouts when patients were recruited with a group of friends. Monetary incentives, (partial refund upon completion of parts of a study, or upon achievement of a behavioural goal) were often used and likely resulted in highly motivated study populations. Notably, effects of social support are hard to distinguish from the effects of financial commitment. Attendance rates were not presented in three of the 10 studies in our review. In the remaining seven studies, attendance rates varied considerably.
The outcome measures of the interventions in Table 1 varied largely. Even a straightforward outcome such as weight was presented in multiple different ways, for example, as a percentage above desirable weight defined by life or health insurance companies, or as the percentage of the study population being overweight or obese. This makes a meta-analytic effectiveness evaluation complicated. Overall, most of the interventions in Table 1 showed beneficial outcomes of the intervention. Similar findings were also reported in the reviews of Black et al (1990) and Kelsey et al (1997). A true evaluation of the effectiveness of the social support component of the interventions is difficult because social support was often not clearly defined, combined in an intervention with other intervention activities, or not included as an outcome measure (Black et al, 1990; Parham, 1993).
Implications: social support in future research and interventions
This review discusses the rationale for social support components in lifestyle-focused interventions for weight management. Despite the strong theoretical framework, a theoretical framework for social support interventions is hardly ever presented in the empirical research literature (Bourgeois et al 1996; Turner & Shepherd, 1999; Helgeson & Gottlieb, 2000). The evidence on social support interventions on weight management summarized in Table 1 generally shows positive outcomes of social support interventions. Earlier reviews by Black et al (1990) and Kelsey et al (1997) also showed positive effects of social support. The first and foremost concern in the social support literature is the heterogeneity of definitions, operationalizations and measurement tools for social support, which hampers comparisons across studies, combined with the lack of a social support outcome measures in most of the studies.
The evidence on social support thus far, suggesting beneficial effects on health, need to be interpreted with care because of possible publication bias.
As behaviour change is a complex process, the use of multicomponent intervention approaches is advocated (Perri et al, 1993; Calfas et al, 2002). As a result, social support is often combined with other intervention approaches. This limits the possibility to accurately assess the separate effects of social support. Also, it is common practice to control for known covariates such as smoking, physical exercise and diet, when assessing the effects of risk factors on health. However, as social support affects these covariates too, controlling for these variables reduces the discernible effects of social support (Knox & Uvnäs-Moberg, 1998). As both informational support and more traditional educational activities provide patients with knowledge and skills, it would be relevant to assess the difference in the effectiveness of both approaches. However, as peers may give informational support as well as emotional support at the same time, distinguishing the relative contribution of each of the support components may be difficult. This also complicates an intervention trial evaluating social support.
Although the evidence supporting tailored lifestyle counselling interventions using the Stages of Change Model (Prochaska & Velicer, 1997) remains limited (Adams & White, 2005), many practitioners as well as researchers recognize the difference between unaware, unmotivated, and unskilled patients (see Verheijden et al in this supplement for a more elaborate discussion on the Stages of Change Model in dietary change). Surprisingly, the Stages of Change Model was not used for any of the interventions included in our review, despite the specific role of social support in the process of the Stages of Change Model. Amick and Ockene (1994) stated that ‘different degrees of social support may be more effective or necessary at one stage than another, making it necessary to identify and emphasize appropriate support resources and activities in intervention efforts’. Since their review, which did not address the preparation stage, surprisingly few studies in this area have been conducted. One study by Joseph et al (2001) showed positive behavioural outcomes of a peer intervention for diabetes patients based on the Stages of Change Model, but clinical outcomes were not assessed. The limited use of tailoring in social support interventions (Lakey and Cohen, 2000) is also surprising because it has been shown repeatedly that characteristics of the recipient and the provider, as well as of the type of disease, determine the need for and exchange of social support (optimal matching theory) (Cutrona & Russell, 1990; Kahn, 1994; Hupcey, 1998; Helgeson & Gottlieb, 2000).
The need for time- and cost-effective lifestyle counselling approaches in health care is evident. This also explains the tendency to study social support predominantly in relation to clinical outcomes with a direct relation to morbidity and mortality. Very few studies have incorporated use of the health care system as a study outcome. McBride and Rimer (1999) showed that supportive telephone calls can reduce the number of scheduled and unscheduled clinic appointments as well as the use of medication and the length of hospital stays. Future studies should show if social support lifestyle interventions can truly serve as a partial substitute for regular health care. In these studies, clinical outcomes that have a direct relation to morbidity and mortality, and therefore to health care costs, are evident measures of effectiveness. WHO's (1946)definition of health, however, is ‘a state of complete physical, mental and social well being and not merely the absence of disease or infirmity’. Therefore, psychosocial measures such as quality of life and patient satisfaction, of which the direct financial benefit to the health care system are hard to quantify, should also be taken into account.
The theoretical rationale for social support in lifestyle interventions is strong. While the rationale for incorporating support in Stages of Change-based interventions is just as strong, there is hardly any evidence from intervention trials. The results of social support in nonstaged interventions are sometimes conflicting, but suggest beneficial effects of the inclusion of social support in interventions aimed at long-term health behaviour change. Adding social support to lifestyle interventions programs has the potential to reduce workload for health professionals, and is appreciated by at least part of the patient population. Many questions need to be answered, however, before social support interventions can be successfully implemented. First and foremost, we need to find out if increasing structural support, which seems to be the method of choice in practice, can lead to increased functional support. We also need to realize that a very successful intervention strategy for one type of behaviour may not initiate change in another health-related behaviour. We need to know more about why, how, and for whom particular characteristics of functional and structural support are beneficial.
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We thank Teresa Broers and Rachelle Seguin from Queen's University's Family Medicine Centre in Kingston, Canada for their help during the preparation of this manuscript. The Netherlands Heart Foundation and the Stichting Dr Catharine van Tussenbroek are gratefully acknowledged for their financial support.
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Verheijden, M., Bakx, J., van Weel, C. et al. Role of social support in lifestyle-focused weight management interventions. Eur J Clin Nutr 59, S179–S186 (2005). https://doi.org/10.1038/sj.ejcn.1602194
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