Developing a Weight-Neutral Health Intervention in Denmark: Protocol for a Co-Design Process
Authors: Meyer Lene , Køster-Rasmussen Rasmus , Christiansen Ann-Kathrin Lindahl , Heitmann Berit Lilienthal , Vesterlund Gitte Kingo , Larsen Sofus Christian , Specht Ina Olmer , Thorsteinsdottir Fanney , Steinbo Emma Katrine Frøhlke , Appel Clara Lundmark , Sigurdardottir Gudrun Agusta , Reventlow Susanne , Waldorff Frans Boch , Sandholdt Catharina Thiel 
Published: October 2024

Abstract

Background
Lifestyle interventions for weight loss are generally ineffective in achieving clinically meaningful long-term reductions in body weight and may contribute to negative behavior such as weight cycling or disordered eating. Negative focus on high weight may also contribute to weight stigma. Weight stigma includes negative attitudes and discriminatory behavior toward people with big bodies and can result in psychological stress and unfavorable health outcomes. Taken together, it is possible that the potential harms of lifestyle-based weight loss interventions may exceed the potential benefits. Weight-neutral health (WNH) has emerged as an alternative strategy advocating for size diversity, intuitive eating, and joyful physical movement, all without placing emphasis on weight reduction.

Objective
This protocol outlines the study design for the co-design process of developing a WNH complex intervention, engaging relevant stakeholders in Denmark.

Methods
We base our understanding of WNH on the principles from Health at Every Size: body acceptance, joyful movement, intuitive eating, and weight stigma reduction. The co-design development process is based on the Medical Research Council’s framework for complex interventions and applies methods from human-centered design through 4 iterative design phases of engaging stakeholders—discover: search existing literature, and conduct interviews with Danish municipal stakeholders working with WNH and other expert stakeholders; define: coproduction of seminars with health professionals (HPs) with knowledge of WNH, and semistructured interviews with people with BMI≥30 kg/m2 who have participated in existing WNH interventions; design: content-creating workshops with HPs and people with BMI≥30 kg/m2; and validate: evaluate seminars, plan feasibility, and produce materials. The data will be analyzed thematically to build a scaffold for the intervention activities and components. In further analysis, we will explore how health is performed, meaning the actions and dialogues that arise when dealing with health guidelines, the societal body, weight, and health expectations, in the context of the intervention.

Results
The project is fully funded. As of August 2024, the co-design process was in the closing phase. In total, 15 HPs were included, some of whom have larger body sizes. This provides a dual perspective, combining their personal experiences of living with a high BMI with their professional expertise. In total, 16 people with BMI≥30 kg/m2 have generously shared their experiences with WNH programs, including the difficulties of moving away from external demands and personal wishes for weight loss. Their contributions have nuanced and unfolded our understanding of the principles of WNH in a Danish setting.

Conclusions
The intervention designed in and from the co-design process will be tested for feasibility in 2025. The findings from the feasibility study will inform a future randomized controlled trial and present novel findings in the field of health management. The long-term goal is to implement the intervention in a Danish municipal setting free of charge.