Strengths and limitations of this study

The semistructured interviews conducted in this study centred on the experiences and perspectives of individuals living with overweight/obesity and early type 2 diabetes in a modern urban environment. These experiences and perspectives provided some of the contextualised understanding needed to unpack extant quantitative research that weight management for diabetes remission in naturalistic settings is possible.

The participant-led interviews enabled participants to describe the aspect of their lived experience that was important to them—weight management for diabetes remission through lifestyle change, namely, diet management; and might account for the relative infrequent descriptions of blood glucose control and medications.

As a qualitative study, the method could not weigh the intrapersonal, interpersonal or environmental barriers vis-à-vis one another nor assess the relative weights of the various socioecological factors identified here to determine which clusters of factors were more influential for losing and maintaining weight loss and diabetes remission.

Introduction

Weight loss can reverse the underlying metabolic abnormalities of type 2 diabetes.1–3 Loss of at least 10% of bodyweight in people with type 2 diabetes produces a disease-modifying effect and can lead to remission, an outcome that is not attainable by glucose-lowering interventions alone.1 2 The impact of weight on type 2 diabetes is so strong that weight loss of 5%–15% is now a recommended primary target in management of diabetes.1 2 Furthermore, biochemical remission of diabetes has been shown to be achievable in the absence of pharmacological or surgical intervention.4–8 For example, in the Diabetes Remission Clinical Trial, about two-thirds of the participants with a type 2 diabetes diagnosis within 6 years returned to non-diabetic levels of blood glucose control after weight loss averaging 15 kg.9 10 Higher levels of weight loss were observed in the intervention group up to 2 years, and participants in the maintenance phase had regular access to dietician or nurse counselling and to a ‘rescue’ plan of diet replacement or weight loss medication.7 Trial participants reported that rapid weight loss motivated them to stay in the programme, and that they needed continuous support from healthcare professionals to sustain outcomes, highlighting the importance of addressing behavioural determinants and provision of appropriate support for initial weight loss and subsequent maintenance.11

Short-term highly restrictive, although highly effective interventions conducted under the close supervision of healthcare professionals may lead to weight loss in the short term.12 However, it is equally important to understand the behavioural, social and environmental factors that contribute to overweight/obesity in people with type 2 diabetes to support long-term weight management. Weight management requires people to make daily choices about food intake and physical activity, and qualitative research seeking to understand participants’ experiences of weight management in naturalistic settings will help identify the key drivers of overweight/obesity. A systematic review and qualitative synthesis of the lived experience of people with obesity found that one of the most powerful themes related to stigma and judgement, with participants experiencing feelings of shame and worthlessness, and living under the critical gaze of others.13 Diabetes clinical care has been seen to be limited by biomedical reductionism, with its emphasis on risk markers such as HbA1c, blood pressure and cholesterol levels, medication and screening for complications to determine treatment.14 People with overweight/obesity and type 2 diabetes have perceived their healthcare providers’ main focus on HbA1c levels to be lacking in empathy, and communication being viewed as unhelpful or offensive.15–17 Such research indicates that patients’ interactions with healthcare providers and family members have impact on their experiences with managing type 2 diabetes and weight management.17

A recent systematic review found that the long-term efficacy of weight loss strategies among Asian individuals with overweight or obesity to be ‘underwhelming’.18 Due to physiological mechanisms and changed behavioural and psychological circumstances, people often regain weight after they have completed a weight management programme.19–22 Researchers underscored the need to pay attention to the distinct behavioural and psychological contexts of weight loss and weight maintenance.21 Exploring these contexts entails learning about real-world conditions and attitudes that influence weight management. Yet, there is a ‘dearth’ of qualitative studies that focus on the experience of the people with weight management, especially within the Asian sociocultural context.13 23 A small body of qualitative research reviewed recently identified the societal, lifestyle and psychological barriers to weight management in Asia.18 23 These included lack of social support, physiological limitations to exercise, low health literacy, with sociocultural norms and lack of accessible healthcare services, exercise facilities and healthy food exacerbating the barriers.18 A Singapore study on participants’ risk perceptions of diabetes identified an additional barrier: a strong food culture and the perceived cost of adopting a healthy diet as being deprived of the pleasure derived from food consumption and social interactions.24

However, few studies have been conducted in people with overweight/obesity and early type 2 diabetes. An understanding of the lifeworld of these individuals and its inherent practices and attitudes could illuminate the sociocultural, physical, emotional and psychological conditions and barriers to weight and diabetes management and how these factors might be interrelated to inform behavioural supports for weight and diabetes management.25 Our study participants came from a diversity of Asian descent living in Singapore, a high-income multiethnic country in Southeast Asia. Discovering more about their lived experiences with overweight/obesity and early type 2 diabetes and how aspects of these experiences interrelate will add to knowledge about attitudes and challenges to weight loss and maintenance in diverse urban environments. To this end, we asked: what are the lived experiences of adults living with overweight/obesity and early type 2 diabetes, and the interrelations between the various aspects of these experiences and participants’ attitudes to weight management?

MethodDesign

We used an inductive qualitative approach to explore through semistructured interviews, the challenges of managing weight and early type 2 diabetes as articulated by patients. We identified patterns of meanings in the data as themes, and used a socioecological lens for conceptualising the interrelations among the themes, where health behaviour is seen to be influenced by the physical and sociocultural environments and the intrapersonal factors.25

Sample

The participants were patients followed up for diabetes at five primary care clinics located in the central and northern parts of Singapore, and referred from their primary care teams. Purposive sampling was conducted based on the inclusion criteria: type 2 diabetes of 6 years or less, and a Body Mass Index (BMI) of 25.0 kg/m2 and above. Recruitment ceased when data reached saturation, defined as when no new intrapersonal, interpersonal and environmental factors were identified.

Ethics and recruitment

The study was approved by National Healthcare Group, Singapore’s Domain Specific Review Board in Singapore (DSRB Reference Number: 2022/00305). Participants gave written informed consent before their interviews began. To protect their identity and privacy, participants were referred to by pseudonyms throughout their interviews, which were conducted in a designated room at the clinic.

Interview procedure

The interviewers were researchers (ML, CK, HSK, MEL) trained in social and clinical sciences. The interview guide (box 1) was developed based on constructs described by the Capability-Opportunity-Motivation and Behavior model—namely, the influences psychological and physical capabilities, conscious and unconscious motivations, and physical and social opportunities have on behaviour.26 Data collection and analysis were conducted iteratively, where the interview questions were adjusted in tandem with the coding process to allow for exploration in greater depth, emergent constructs of interest at subsequent interviews.27 The semistructured interviews, lasting 50–75 min each, were conducted between August 2022 and February 2023, audio-recorded, transcribed verbatim. Interviewees were encouraged to provide detailed descriptions of what they thought were significant in their experiences with managing their weight and diabetes. Informal member checking was performed through clarification and read-back tactics such as paraphrasing and summarising responses at appropriate junctures.

Box 1 Interview guide.

Living with diabetes and being overweight/obesity

What is an important component of your life that you want to share with us? (Probe: It could be your health, it could be this disease. It could be about your work; your family).

Having diabetes and being overweight at the same time—what does it mean for you?

What do you think caused you to have diabetes; be overweight?

I would like a peek into your world and worldview. How would you describe your world, your outlook in life and your lifestyle? How have obesity and diabetes impacted your life and perspective about life?

How do you think you are managing weight and diabetes? Why do you say so?

What is food and eating to you?

What do you think about exercise and physical activity?

Has anything in your life changed since you were diagnosed with diabetes or since you realised you want to lose weight? If yes, what changed?

Have you tried losing weight before—what have your experiences been? What are the challenges/difficulties you face in trying to reduce weight and manage diabetes?

Do you believe you can overcome the difficulties and lower your weight, blood glucose levels or even reverse diabetes? Why? What may hinder you from overcoming these difficulties?

What needs to change in your life and the environment (probes: personal and community’s perspective and approach to food, cooking and eating; work and family life; living conditions; work conditions) for you to better manage your weight and diabetes?

Interaction with friends, family, colleagues and healthcare providers

Who do you live with? Tell me about your family life. What is it like to be in this home day-to-day, especially when it comes to meal times? What can we say about your family’s perspective about food and eating?

How do you see family and friends support in your health management (diabetes and weight)?

How can your healthcare provider help you?

Analysis

Data interpretation was conducted with the completion of each interview, and the data was viewed through a social constructivist lens, examining how the interviewees’ lived experiences were constructed through interaction, experiences and environment. Memoing was carried out and helped the researchers delineate inchoate concepts, reflexively examine their assumptions, and attune themselves to refining their interview methods.27

Four researchers coded the data, with a discrete idea standing as a unit of meaning. The initial codes were couched in gerunds to maintain a dynamic and granular take on what was occurring in a particular unit of meaning.27 Next, codes were selected and grouped around ‘central organising concepts’ or themes.28 The themes were organised into a socioecological framework informed by the research questions. Despite the diversity of the interviewees’ backgrounds, the themes were consistent across the whole dataset, suggesting prevalence of certain barriers. Each theme was fleshed out by subthemes and illustrated with participants’ quotes.

Patients and public involvement statement

There was no patient or public involvement in setting the research agenda. Concerns posed by patients in clinical encounters (eg, recruitment method, sensitivity to having obesity, comfortable interview situation) were taken into account when developing the study design. The results will be shared with the media on acceptance.

Results

A total of 21 participants were recruited: 12 of the participants were female and nine were male. They were between 29 and 59 years old, of Chinese, Indian and Malay ethnicities, with a BMI between 25.3 and 44.0 kg/m2. See table 1 for profile of interviewees.

Table 1

Profile of interviewees as adults living with overweight/obesity (BMI 25.3–44.0 kg/m2) and early type 2 diabetes (≤6 years)

Participants with type 2 diabetes were mostly aware that weight loss would be beneficial for diabetes, and many had either previously made attempts to lose weight or were currently trying to do so. However, most of them were unsuccessful and many challenges were described. The main themes identified were (1) Everyday life, (2) People around me and (3) Within me (figure 1). This socioecological categorisation identified barriers and facilitators of weight management that were either environmental, interpersonal or intrapersonal.

Figure 1

Interrelations among themes and subthemes on the struggles of adults living with overweight/obesity and early type 2 diabetes in Singapore.

Everyday life

Participants were embedded in an obesogenic environment characterised by abundance of food temptations, convenient access to unhealthy foods and having work pressures that affected food choices and physical activity.

Abundance of food temptations

Participants were conscious of the need to eat healthily to control their blood glucose levels. However, they lived in an environment replete with calorie-dense flavourful foods that came in the way of their health. For example, P9 whose workplace was sited in a shopping mall talked about being surrounded by food temptations. P2 described being ‘mentally challenged’ whenever he saw people in restaurants—“It’s just visually tempting … enticing—‘Come to me, have me’. If you go out, you will definitely see food. Food is all around in Singapore, can’t avoid.”

Unhealthy foods seemed more convenient to obtain than healthy foods

Participants could obtain unhealthy foods easily via technology.

Fried food is just convenient. … you order, and get it fast …my lunchtime is not very long, about an hour. So, whatever you can get, you just get… McDonald’s, KFC, they are all about convenience. Because from your phone, you can just order using the app. Then you can just self-collect. It’s more efficient. Saves more time. (P19, male)

Healthy food was apparently less visible.

Less chances [to find healthier choice food in Singapore]. Out of a range of 10 items, probably, you will get three healthy items. (P21, male)

Work pressures affecting food choices and physical activity

Work environments constrained or undermined participants’ diet and physical activity and consequently, health. This included having long working hours or having to work shifts, which led to participants to have ‘no time for anything else’ (P22). P18 regained the 9.0 kg he had lost when he undertook a work project that saw him working 16 hours daily for almost a year: “I used to come home at like 10, 11 o'clock. Then morning six o'clock I go back to work again … 7 days a week, so it was that busy.” During that hectic period, he did not have time to do his daily 8.0 km walk.

Work-related stress also contributed to diminished motivation in adopting healthier eating habits or being more physically active. P10 explained how she regained the 28.0 kg she had lost: “Work stress … nothing to look forward to. No goal to keep me on the lifestyle. I just relaxed myself and then because of work stress … it’s really work stress”. Some participants attributed their development of diabetes and other chronic diseases to work and spoke about wanting to quit their jobs for better mental well-being and the mind-space to make wiser food choices.

I don't have life at all and I think my diabetes is due to this … my work is like that forever … I think [it] will be easier for me to control my weight, my diabetes after I quit. (P6, female)

However, there was a tension of financial insecurity stemming from quitting one’s job too.

So hard to find a job at my age with hypertension. Who wants to hire? [Even if] people hire you, in terms of insurance coverage, I feel that I’m kind of affected by it, so I hold back (tearing). (P4 female)

People around me

Many participants’ family members, friends or colleagues knew of their diabetes diagnosis, and interpersonal factors and social norms at work and home influenced participants’ health behaviour and outlook.

Family influence

Family was both an enabling and constraining factor for healthier diet and physical activity. The maintenance of healthy diets and regular exercise was significantly enhanced when family members joined participants in these endeavours. However, the converse was also true. P3’s sister cautioned her about buying certain foods but would also treat her to restaurants, contributing to consumption of calorie-dense foods. She was also inconsistent in accompanying P3 for walks: “There are moments my sister got lazy, and didn’t want to come (to the park for walks).” Positive reminders from both family members and colleagues also proved beneficial in fostering a supportive environment. P19 worked in a food outlet that served fried food. But he had family and a boss who encouraged him to exercise and reminded him to eat healthier.

Family was frequently a motivator for health behaviour change. In particular, the impact that diabetes might have on their health and the subsequent burden on their children were a strong motivator to maintain good health. P17 lost 10 kg with her dress size dropping from 48 to 40 amid regular reminders from her children to eat wisely and exercise. Similarly, P3’s children were her motivation to lose weight and diabetes: “I do not want to burden my children. That’s the thing that keeps me going. … Kids nowadays are more international. They might migrate to a country where they have a better future. I don't want them to think there is still an old, sick mother [back home in Singapore]”.

Family and friends’ behaviours also inspired change. For P18, his mother showed him that remission was possible with weight and diet management: “My mum had diabetes at the age of 60 and she’s cured of diabetes now. Now she’s 70. Two years ago, she’s cured. She’s off the medication, so she reversed it with her diet. It’s possible. So, when I heard it, she can do it, why not me?

Community and peer support

Many participants shared about the need of peer support, and how it may be the catalyst to eating better or exercising more frequently. P2 felt that people with type 2 diabetes who wanted to lose weight would benefit from ‘a really dedicated community support for people with diabetes’.

If I can find a buddy in this journey, I think I will do very well. No matter how educated you are, how well-prepared you are, I think that having a buddy is very important, because you can remind each other. And this buddy might not necessarily be your loved one or your friend. It’s just somebody who shares the common goal. But I'm not sure how to do that. I need a friend who is diabetic. (laughs) (P3, female)

Sociocultural dietary norms

Adherence to social and cultural norms determined some participants’ dietary practices. P13 and P18 were ethnic Indian and vegetarian. P13’s wife packed a vegetarian lunch including chapati and vegetables like lentils for him to take to the office. He said his wife who enjoyed food was also overweight. While they were aware of the need to eat healthily particularly because of their overweight/obesity and diabetes, their non-meat choices outside the home appeared to be foods with known dietary risk factors (ie, processed foods, fried foods, unrefined carbohydrates).

Weekends, we go to something like an Italian or a Mexican restaurant, that is slightly different … so it could be pasta or pizza or if it’s Mexican, something like an enchilada or burrito. (P13, male)

P18 had at least one homecooked meal a day. Outside the home, he was not fussy about what he ate as long as it did not contain meat:

They have onion rings, fries, or pita bread, whatever they have. If I go to a Japanese place, I’d ask them to make for me something vegetarian – vegetable tempura or edamame or sweet potato, or even sushi with avocado, cucumber, I try everything. (P18, male)

Workplace dietary norms

Colleagues and bosses’ food preferences influenced participants’ food choices and hindered their efforts to maintain a healthy eating regimen.

We’d give ourselves some excuse – ‘Shall we get a drink? … all the bubble tea, the coconut … the things that got me diabetes. … I don't like bubble tea, but my evil friend likes (laughs).’ Then we’d drink together, buy together. I took more bubble tea and more fruit juice than usual. That was the spike. The thing is we didn't know [that fruit juice has high sugar content]. So we always went for Boost Juice. We always went for fruit juices in the hawker centre. I took quite a fair bit and then in mid-June, when I came for the check-up, it shot up to 9.3 or 9.6. The doctor got a shock. I did another blood test one week later – 9.3. (P9, female)

P4 might have felt that she was missing out if she consumed a clinically calibrated liquid meal replacement.

My bosses like to go to eat … Korean food. Their Korean food is normal like kimchi ramen … they get the taste, the savoury taste. But what I get is the milk [liquid meal replacement]. (P4, female)

Within me

Intrapersonal characteristics and responses were important influences on an individual’s propensity towards behaviour change.

Prioritising work

Embedding participants with a strong sense of professional responsibility in a high-pressure work environment left them sacrificing dinner and sleep. P4 admitted that she could not let go of work: “I want to finish whatever I think I can finish and I don’t want to do halfway and give you low quality work … So I will stick there until 8.30. I don't even take the Optifast sometimes. I just … drink one Milo … It’s not that I don't feel like eating (dinner). I want to eat, but (late dinner is) not good for me”. On other occasions, dinner consisted of nutritionally empty food. “Sometimes, I don't eat. I just eat rubbish – my office provides biscuits, sometimes peanut biscuits, Milo”.

P6 worked on most days of the week. She had even worked through the night in the office, completing an assignment she had promised to deliver to another department.

My diabetes is also due to … overwork until I forgot to eat. I don't feel hungry but when I feel hungry, sometimes my stomach is like very painful. I got no strength, shiver like that. Maybe the blood sugar is too low already. My family would ask me, ‘How come you are so really overworked, you don't know when you are hungry?’ Sometimes I’m too stressed, I just want to finish the meal. I don't have time to sit there and slowly eat and my dinner is always past midnight because sometimes I need to rush reports … I also don't have the mood to eat … I always wake up during the night around 3am, I’d get up and think, ‘Tomorrow the first thing what should I do for my work … my work is like that forever.’ (P6, female)

Responding to risks

Participants’ perception of their susceptibility to diabetes complications impacted their motivation to lose weight. For example, P15’s father’s experiences with diabetes complications which led to an early death affected her own behaviour.

There’s nothing I can do about it except live better than Dad did. Don't get myself into the extremes. Manage it as much as I can, watch my diet, exercise, just being aware of this condition. Of course if I could lose weight more easily, that would be a plus point for the diabetes itself, and the cholesterol. (P15, female)

Valued self-identity

Several participants wanted to be perceived as thriving persons who had their lives and weight under control despite their chronic conditions. P15 would make extra effort to always look groomed. After she left her job, P6 felt that losing weight would give her a sense of accomplishment:

I'm not working already and I got no income but at least I must achieve something. I cannot be not working, not earning money and still look like my previous self. I was telling myself, I need to have a change. I don't want people to say, ‘Now you’re not working, but you’re still looking so fat’. I want my colleagues to say, ‘Now that you’re not working, you look younger.’ I’ll be so happy then. So I tell myself, ‘Okay, I must really slim down’.

Dealing with co-existing conditions

Overweight/obesity was associated with knee and back pain, and pain stopped some participants from leading an active life. In addition, their stamina was affected by excess weight and years of sedentary lifestyle. For example, P15 sustained two falls and was told to stop dance class, and P16 had arthritic knees. P1 hesitated to go hiking with friends because of her bad knees and swollen feet: “Walking gives problem… walk a bit, swollen … I think is because I’m fat … my legs cannot hold the pressure. My tummy is big, my feet are small … I take bus, they let me sit. They don’t know my age, think I’m pregnant”.

Regulating self

Participants encountered psychological challenges pertaining to motivation, self-discipline and problem-solving.

Inertia

Participants’ sedentary lifestyle engendered inactivity and inertia.

Weekends … we will sleep until really late … Then … we will order breakfast from McDonald’s, Burger King, whatever that’s convenient from GrabFood … Then we will watch Netflix… (laughs). And fall asleep in front of the TV, wake up, eat again. (P14, female)

P14 did not initiate behaviour change immediately when told she had pre-diabetes: “I just didn’t see it (blurred vision and diabetes diagnosis) coming. I cut myself too much slack”. Coupled with her bad knees, P1 was inclined to be sedentary: “I’m lazy. Never exercise. I go home, I shower, lie down on the bed already. So never even walk”.

Many participants found it difficult to stay motivated and described how they would revert to previous behaviours. P20’s used to drive to office but began taking the bus after being told that he had diabetes: “So I try to change that. At least right now, I'm still doing it. I'm still at least walking to the bus stop once every day.” He also changed his diet and started taking the stairs. However, he reverted to his sedentary behaviour a month after.

Discipline

Participants shared about the importance of self-discipline, which was usually framed as refraining from sugary food or making the effort to prepare healthy meals.

Because you always have a choice. Whether you want to follow through or not. My plan and goal are to reverse this. I keep that in mind. Every time I want to have a sweet drink, I tell myself, ‘No. This one is for the long run. Having a sweet drink now might not hurt me in the short run. But what I want to do in the long run is to reverse this. So, I should just give it up’. (P19, male)

P2’s pre-dawn meal preparations attest to his self-discipline:

I wake up at 4.30… I do that when I need to go to the gym. So I wake up early and prep the food, like chicken and salad. And probably eat that for lunch. (P2, male)

However, for most participants, losing weight was a balancing act. P15 rationed foods high in carbohydrate and sugar content (eg, cakes during office parties) but would also indulge at times. Although she watched her weight, she would regain what she had lost, and then try to lose it again.

Problem-solving

Several participants adopted a problem-solving attitude. They acknowledged the effort needed but were determined to lose weight. P2 had lost about 30.0 kg on his own: ‘…when there’s a sickness, there has to be a cure’. P18 approached his recent diagnosis of diabetes with a self-improvement mindset: “It’s more of an achievement if you overcome the problem. You learn and move on”.

To P21, diabetes was not a terminal disease, and negativity would not help his situation: “I'm like that from young. I learn at a young age that being negative or being drastic or being down doesn't help the situation”. Instead, he dealt with his health challenges by going for walks with his wife and working out with YouTube programmes, and saw Metformin as enhancing his health.

Meanings of food

Food embodied affective meanings for participants. Food was solace. For example, the overworked P10 would have the refined high-carbohydrate snacks she purchased from the neighbourhood supermarket as supper.

During weekdays, it’s food that gives me comfort … it’s really comfort food. Any kind of food: I like to eat potato chips … crackers … peanuts a lot. Just to tell myself this is the fruits of my labour. (P10, female)

Food gave participants happiness and pleasure.

Fast food links to a childhood memory of happiness. I think this could be one thing behind it. I tend to eat Big Mac meals. Just eat, … forget about everything. Just eat the fries, drink your Coke. Maybe this indirectly contributes to a childhood [memory] where fast food was a happy time. (P11, male)

Discussion

A socioecological perspective offers a conceptual framework for understanding the environmental, interpersonal and intrapersonal factors at play in the everyday life of persons living with overweight/obesity and early type 2 diabetes.25 Figure 1 depicts the interrelations among the environmental (Everyday life), interpersonal (People around me) and intrapersonal (Within me) factors that hinder or facilitate participants from achieving weight loss and diabetes remission. The themes interrelate to form an overall understanding that the modern urban environment is a highly obesogenic one, and that adults managing overweight/obesity and early type 2 diabetes will require additional support to overcome these challenges.

The easy availability of calorie-dense food in the modern environment (Everyday life), be these from food courts, fast food outlets, online or the neighbourhood supermarket posed temptations to participants. This is a significant challenge because 77.3% of Singaporeans eat out for at least one meal every day.29 Participants ate unhealthy foods for their tastiness and feel-good factor (Within me). Other environmental factors like long working hours and work stress (Everyday life) led participants to favour flavour over health when making food choices. Family and peer influences also influenced food choices especially when eating out as a group. In type 2 diabetes, dietary choices do not just have an impact on weight but on glycaemic control as well.30 Our findings highlight the need for research on more effective methods to address environmental challenges. Studies have found a link between work stressors and predisposition towards type 2 diabetes.31–33 However, effective strategies for supporting people with type 2 diabetes in coping with work stress are lacking, and workplace environments and policies will have to be reviewed to support better overall health.

While participants attributed their health condition to a matter of self-discipline (Within me), their everyday lives revolving around overworking and maladaptive eating pointed to mental well-being challenges (Within me). Work-related stress (Everyday life) as a significant factor undermining the self-regulation and problem-solving needed for change is well-noted in clinical studies.34 However, participants (eg, P2 and P18) who believed they could overcome their chronic diseases, took on a problem-solving approach. They were sanguine they could get their blood glucose under control and even help others accomplish likewise (People around me). This finding is corroborated with evidence that self-regulation makes a difference to changing behaviour.35 The participants described a sedentary lifestyle accumulated over years of prioritising work over physical activity. The built environment in Singapore is inclusive, safe and designed for active living.36 Problem-solving strategies could leverage on this infrastructure to incorporate physical activity into everyday life.

Family and peer support (People around me) could make a difference in the participants’ pursuit of better mental and physical health. Family and friends enable and constrain the participants’ efforts to initiate and maintain behaviour change. As in extant research and theory, family as role models in particular, boost participants’ optimism and motivation to change.37–39 Participants who were vegetarian (People around me) might perceive their diet to be healthier but still faced weight issues. While they seemed to have more home-cooked (presumably, healthier) meals, they might have been eating higher proportions of refined carbohydrates and fried foods outside the home.40 Information on healthy eating for people with special diets may be less accessible and more targeted dietary education may be needed.

The results suggest that improving the sociocultural and physical environments by promoting healthier foods options among food providers and at the workplace; strengthening family and peer support (Everyday life; People around me); and promoting mental wellness to engender self-regulation (Within me) may be what is collectively needed to facilitate weight and diabetes management to occur at the individual level.35 The interrelations among environmental, interpersonal and intrapersonal factors highlight the need for a whole-system approach to achieve and sustain weight management in individuals with overweight/obesity and early type 2 diabetes, especially if aiming for diabetes remission.41 42

This qualitative study revealed the experiences and perspectives of individuals having overweight/obesity and early type 2 diabetes in a modern city-state. The semistructured interviews in this study allowed participants to describe the aspects of their lived experiences that were important to them—managing weight through lifestyle change that could lead to diabetes remission and might account for the relative infrequent descriptions of blood glucose control and medications. The results rendered a more contextualised understanding of the challenges individuals face in managing their weight, and with that, diabetes in a modern urban environment. This understanding could facilitate the development of individualised interventions. However, it should be noted that in adopting a qualitative methodology, we could not weigh the intrapersonal, interpersonal or environmental barriers vis-à-vis one another nor assess the relative weights of the various socioecological factors identified here to determine which clusters of factors were more influential for losing and maintaining weight loss and diabetes remission.

The conceptualisation of the results as interrelated factors answers the call for a socioecological approach to supporting people with diabetes and obesity.43 Interventions could then address the social, emotional, physical and psychological needs of the individual integratively.43 For example, enhancing work-life balance and stress management by the government and employers could ameliorate the impact of overworking on the individual’s mental well-being and health management, while promoting stronger support from family and peers could further enable them. Online food delivery is a known risk factor for sedentary lifestyle and chronic diseases.44 Consumer education can increase nutrition literacy to promote healthier online food choices.44 At the same time, the ongoing national initiative, Healthier SG that focuses on preventive care through healthy, active living would be useful for promoting incorporation of physical activity into everyday life.45

Our results may be transferable to similar groups in other modern economies. Nonetheless, further research is needed to assess the relative weights of the various socioecological factors identified here to determine which clusters of factors are more influential for losing and maintaining weight loss and diabetes remission.

Conclusion

An exploration of the lived experience of patients with overweight/obese and early type 2 diabetes revealed environmental, interpersonal and intrapersonal factors that contributed to overweight/obesity. The results suggested that an integrated approach, focusing on improving sociocultural and physical environments, strengthening family and peer support and promoting mental wellness to engender self-regulation, may be what is collectively needed to facilitate weight and diabetes management to occur at the individual level.

Data availability statement

Data are available upon reasonable request. Data from interview transcripts may be available upon reasonable request and within legal and ethical conditions.

Ethics statementsPatient consent for publication

Obtained.

Ethics approval

This study involves human participants and was approved by National Healthcare Group, Singapore's Domain Specific Review Board (DSRB Reference Number: 2022/00305).

Acknowledgments

The authors express appreciation to the study participants. They also thank the healthcare staff at the polyclinics, Dr Sabrina Lee for overseeing the administrative matters of the project, and Ms Shannon Goh for assistance in recruiting and scheduling participants.