Advertisement

Patient motivation to lose weight: Importance of healthcare professional support, goals and self-efficacy

Open AccessPublished:February 05, 2021DOI:https://doi.org/10.1016/j.ejim.2021.01.019

      Highlights

      • Comfort when talking to healthcare professionals was linked to weight loss motivation.
      • Those motivated often regarded healthcare professionals as an information source.
      • Weight loss motivation was associated with exercise, goal setting and peer support.
      • Knowing how to lose weight and ease of weight loss increased the odds of motivation.
      • Understanding weight loss motivations may improve support for people with obesity.

      Abstract

      Background

      People with obesity (PwO) often struggle to achieve and maintain weight loss. This can perpetuate and/or be influenced by feelings of low motivation. This analysis from ACTION-IO data identified factors associated with PwO motivation to lose weight.

      Methods

      PwO completed an online survey in 11 countries. Exploratory multinomial logistic regression analyses identified independent variables associated with self-report of feeling motivated versus not motivated to lose weight.

      Results

      Data from 10,854 PwO were included (5,369 motivated; 3,312 neutral; 2,173 not motivated). Variables associated with feeling motivated versus not motivated included (odds ratio [95% confidence interval]): acknowledgement of healthcare professional (HCP) responsibility to contribute to weight loss (2.32 [1.86–2.88]), comfort in talking to their HCP about weight (1.46 [1.24–1.72), agreement that it is easy to lose weight (1.73 [1.30–2.31]), and a goal of reducing risks from excess weight (1.45 [1.22–1.73]). Conversely, if PwO considered obesity less important than other diseases they were less likely to report feeling motivated (0.49 [0.41–0.58]). PwO who reported being motivated to lose weight were more likely to exercise ≥5 times a week versus <1 time a week (2.77 [2.09–3.68]) than those who reported they were not motivated.

      Conclusions

      Positive interactions with HCPs, self-efficacy, setting goals and knowledge of the importance of weight management, in addition to regular exercising, may increase PwO motivation for weight loss. Appropriate HCP support may help PwO who are ready to engage in weight management.

      Clinical trial registration

      : NCT03584191.

      Graphical abstract

      Keywords

      Abbreviations:

      ACTION-IO (Awareness, Care, and Treatment In Obesity maNagement International Observation), HCP (healthcare professional), PwO (people with obesity)

      1. Introduction

      Obesity is a global health concern [
      GBD 2015 Obesity Collaborators
      Health effects of overweight and obesity in 195 countries over 25 years.
      ]. Multiple complications are associated with overweight and obesity including diabetes, heart disease, musculoskeletal disorders and some cancers, and people with obesity (PwO) are at an increased risk of disability and suffer social stigma [
      • Guh D.P.
      • Zhang W.
      • Bansback N.
      • Amarsi Z.
      • Laird Birmingham C.
      • Anis A.H.
      The incidence of co-morbidities related to obesity and overweight: a systematic review and meta-analysis.
      ,
      • Djalalinia S.
      • Qorbani M.
      • Peyraki N.
      • Kelishadi R.
      Health impacts of obesity.
      ,
      • van der Klaauw A.A.
      • Farooqi I.S.
      The hunger genes: pathways to obesity.
      ,
      • Puhl R.M.
      • Heuer C.A.
      Obesity stigma: important considerations for public health.
      ]. In the current time, the risk that obesity poses has been highlighted; it increases the risk for serious complications from viral infections, and in particular is associated with high mortality risk of COVID-19 and H1N1 infections [
      • Honce R.
      • Schultz-Cherry S.
      Impact of obesity on influenza A virus pathogenesis, immune response, and evolution.
      ,
      • Kassir R.
      Risk of COVID-19 for patients with obesity.
      ,
      • Kass D.A.
      • Duggal P.
      • Cingolani O.
      Obesity could shift severe COVID-19 disease to younger ages.
      ,
      • Caussy C.
      • Pattou F.
      • Wallet F.
      • et al.
      Prevalence of obesity among adult inpatients with COVID-19 in France.
      ]. Losing weight and maintaining weight loss is a struggle for PwO due to the complexity of obesity and the range of contributing factors – physiological, genetic, environmental and psychosocial [
      • Lemstra M.
      • Bird Y.
      • Nwankwo C.
      • Rogers M.
      • Moraros J.
      Weight loss intervention adherence and factors promoting adherence: a meta-analysis.
      ]. We have reported previously that only 11% of 14,502 PwO surveyed had a loss of 5% body weight or more that was maintained for at least 1 year [
      • Caterson I.D.
      • Alfadda A.A.
      • Auerbach P.
      • et al.
      Gaps to bridge: misalignment between perception, reality and actions in obesity.
      ].
      Adherence to weight loss interventions and sustained motivation for weight loss is important for weight management. A study by Webber et al. showed that individuals who achieved 5% weight loss after a 16-week intervention had sustained motivation for the whole of the 16-week study [
      • Webber K.H.
      • Tate D.F.
      • Ward D.S.
      • Bowling J.M.
      Motivation and its relationship to adherence to self-monitoring and weight loss in a 16-week internet behavioral weight loss intervention.
      ]. Participants who did not achieve 5% weight loss had shown decreased motivation over time [
      • Webber K.H.
      • Tate D.F.
      • Ward D.S.
      • Bowling J.M.
      Motivation and its relationship to adherence to self-monitoring and weight loss in a 16-week internet behavioral weight loss intervention.
      ]. The study also found that motivation at 4 weeks was a predictor of adherence to self-monitoring and 16-week weight loss [
      • Webber K.H.
      • Tate D.F.
      • Ward D.S.
      • Bowling J.M.
      Motivation and its relationship to adherence to self-monitoring and weight loss in a 16-week internet behavioral weight loss intervention.
      ]. Good mental health may contribute to motivation and adherence, since better mental health has been associated with sustained weight loss outcomes [
      • Brantley P.J.
      • Stewart D.W.
      • Myers V.H.
      • et al.
      Psychosocial predictors of weight regain in the weight loss maintenance trial.
      ]. Incorporating aspects of social support showed high adherence rates for weight loss interventions and even had a reduced risk of premature mortality in some studies [
      • Lemstra M.
      • Bird Y.
      • Nwankwo C.
      • Rogers M.
      • Moraros J.
      Weight loss intervention adherence and factors promoting adherence: a meta-analysis.
      ]. However, it should be noted that once someone has lost some weight, a cascade of events take place in the body to prevent further weight loss, including a reduction in energy expenditure [
      • Leibel R.L.
      • Rosenbaum M.
      • Hirsch J.
      Changes in energy expenditure resulting from altered body weight.
      ] and changes in the hormones that regulate energy reserves and satiety in the body and, subsequently, appetite control [
      • Sumithran P.
      • Prendergast L.A.
      • Delbridge E.
      • et al.
      Long-term persistence of hormonal adaptations to weight loss.
      ]. As a result of these biological mechanisms, people find it difficult to continue to lose and maintain their weight loss [
      • Sumithran P.
      • Prendergast L.A.
      • Delbridge E.
      • et al.
      Long-term persistence of hormonal adaptations to weight loss.
      ], even if they are still adhering to weight loss interventions [
      • van der Klaauw A.A.
      • Farooqi I.S.
      The hunger genes: pathways to obesity.
      ,
      • Ghanemi A.
      • Yoshioka M.
      • St-Amand J.
      Broken energy homeostasis and obesity pathogenesis: the surrounding concepts.
      ].
      In order to determine which factors might contribute to motivation for weight loss and be associated with a successful response to weight loss efforts, we performed exploratory regression analyses of PwO data from the Awareness, Care, and Treatment In Obesity maNagement International Observation (ACTION-IO) study.

      2. Methods

      2.1 Study design

      ACTION-IO was a cross-sectional, non-interventional, descriptive study that collected data from 11 countries (Australia, Chile, Israel, Italy, Japan, Mexico, Saudi Arabia, South Korea, Spain, the UAE, and the UK) via an online survey [
      • Caterson I.D.
      • Alfadda A.A.
      • Auerbach P.
      • et al.
      Gaps to bridge: misalignment between perception, reality and actions in obesity.
      ]. The study aimed to identify perceptions, attitudes, behaviours and potential barriers to effective obesity care amongst PwO and healthcare professionals (HCPs). Eligible PwO were at least 18 years of age and had obesity based on self-reported height and weight and per country-specific definitions (body mass index [BMI] ≥25 kg/m2 in Japan and South Korea and ≥30 kg/m2 in all other participating countries) [

      International Association for the Study of Obesity (IASO). The asia-pacific perspective: redefining obesity and its treatment. https://apps.who.int/iris/bitstream/handle/10665/206936/0957708211_eng.pdf?sequence=1&isAllowed=y. February 2000.

      ]. PwO were recruited through email in all participating countries, with telephone and in-person recruitment also used in Saudi Arabia and the UAE. Email recruitment was conducted via online panel companies to participants whom had given permission to be contacted for research purposes. Prior to participation, PwO were blinded to the specific study goals, being informed that the purpose was “to determine treatment experiences of patients with a specific condition”. A stratified sampling approach for PwO was used, whereby recruitment into the study was according to pre-determined demographic targets based on gender, age, income, race/ethnicity (in select countries) and region. Targets were monitored throughout data collection to ensure population representativeness. A set of screening questions were used to determine eligibility based on the demographic targets, BMI requirements and other study eligibility criteria, and only those who qualified for the study completed the full survey. All respondents provided electronic informed consent prior to initiation of the screening questions and survey. To ensure that the group was largely representative of the general population, the PwO sample, including those failing to qualify for the survey, was also weighted to the representative demographic targets within each country. Weights were calculated using the statistical method of raking, which adjusts sampling weights to match population totals along each demographic margin. The representative demographic targets were based on data from the 2011 International Standard Classification of Education, the US Census Bureau International Data Base and other public data, and included age, gender, household income, education and region. The data from each individual country were weighted to the representative demographic targets for that particular country. Questionnaire items were carefully phrased and presented in the same order for each respondent and items in a list were displayed alphabetically, categorically, chronologically or randomly, as relevant for each response set and to avoid bias. The study was registered with ClincalTrials.gov (NCT03584191) and conducted in accordance with the Guidelines for Good Pharmacoepidemiology Practices and the Declaration of Helsinki.
      A multinomial logistic regression model was used to investigate independent variables associated with feeling motivated versus not motivated, and feeling neither motivated nor unmotivated (neutral) versus not motivated, to lose weight. The PwO subgroups were arbitrarily established and derived based on responses to a survey question asking the participants to indicate how much they agreed with the statement “I am motivated to lose weight”. PwO selected their answer based on a scale where 1 means “Do not agree at all” and 5 means “Completely agree”. Those responding with 4 or 5 were considered to be motivated to lose weight, 3 to be neutral, and 1 or 2 to be not motivated to lose weight. The neutral group was not combined with either the motivated or not motivated groups to ensure these populations were distinct from each other. The neutral group was included in the model, rather than being omitted, to investigate whether there were independent variables associated with a neutral versus not motivated disposition. As such, a multinomial logistic regression model was required for inclusion of all three groups.
      Logistic regression models were used to investigate independent variables associated with at least a (a) 5% or (b) 10% weight loss in the past 3 years that was maintained for at least 1 year. Percentage weight loss was calculated from responses to questions asking the participants’ current weight and the most they have weighed in the past 3 years. If the participants’ current weight was less than their maximum weight within the past 3 years, they were asked how long they had been able to maintain the weight loss. Responses to these questions were used to apportion the PwO into the relevant subgroup. Inaccuracies due to the self-reported nature of the data cannot be precluded.

      2.2 Data analysis

      Potential independent variables were grouped into three domains: attitudinal, behavioural, and demographic. Relevant variables for the models were identified and necessary transformations for use in the models were outlined. Prior to model development, the data were cleaned and transformed (see the supplementary appendix for more details). An analytics dataset of 10,854 records and 141 variables was obtained from a starting dataset of 14,502 records and 683 variables. All data were analysed using the R statistical language [

      The R Foundation. R: a language and environment for statistical computing. 2020. https://www.R-project.org/.

      ].
      A systematic process was created to ensure reproducibility and consistency across the models. All potential independent variables were identified, and bi-variate odds ratios and confidence intervals were calculated; all significant odds ratios were ordered by their absolute impact and quartile thresholds were calculated; all variables with significant odds ratios in the 3rd and 4th quartiles were kept, and an initial multi-variable model (multinomial or logistic as appropriate) was created. The number of variables was algorithmically reduced in the models: for the multinomial model, variables were iteratively removed from the model with the largest p-value above 0.05; for the logistic models, Bayesian variable selection [
      • Scheipl F.
      spikeSlabGAM: bayesian Variable Selection, Model Choice and Regularization for Generalized Additive Mixed Models in R.
      ] was used to calculate marginal posterior inclusion probabilities for each variable and variables with an inclusion probability greater than 0.25 were kept. Variables with uninterpretable effects were manually removed (see the supplementary appendix for variables removed per this criterion). Variables of clinical relevance or significance, not already in the model, were added to the model and kept if they were significant and improved model fit. Model diagnostics were performed on residuals, general fit, and predictive accuracy (assessed over five-hundred training/test splits); models that adequately passed were kept. For motivation this yielded 13 models in total, for maintenance of 5% body weight loss this yielded 8 models in total, and for maintenance of 10% body weight loss this yielded 7 models in total. The final models were selected for model fit and predictive capacity.

      2.3 Role of the funding source

      This study was designed by the study steering committee members (all are authors and include representatives of the study sponsor) and KJT Group (Honeoye Falls, New York, USA). Data collection and analysis was undertaken by KJT Group. All authors interpreted the data, contributed to manuscript development, and approved the submitted version. The corresponding author had full access to all the study data and had final responsibility for the decision to submit for publication.

      3. Results

      As previously described [
      • Caterson I.D.
      • Alfadda A.A.
      • Auerbach P.
      • et al.
      Gaps to bridge: misalignment between perception, reality and actions in obesity.
      ], 14,502 PwO completed the survey, in accordance with the target sample size for the 11 participating countries. Of these PwO, 10,854 had complete data for the variables in the models and were included in the regression analyses.

      3.1 PwO motivation

      Half of the PwO (n = 5369) reported that at the time they took the survey, they were motivated, and the rest reported they were not motivated (n = 2173) or provided a neutral response (n = 3312). Demographics and characteristics of the participating PwO are summarised in Table 1. Variables significantly associated with PwO reporting they were motivated for weight loss are presented in Fig. 1. The data for the neutral group are presented in Supplementary Fig. S1, and were largely consistent with being an intermediate group between the motivated and not motivated groups. PwO who agreed that they are motivated to lose weight were more likely to report that they exercise for at least a 20-minute period at least once a week compared to never or less than once a week. The odds were increased by a factor of 2.12 (95% confidence interval [CI], 1.79–2.52) for 1 to 4 times a week and 2.77 (95% CI, 2.09–3.68) for 5 or more times a week.
      Table 1Participant demographics and characteristics.
      Motivated (n = 5369)Neutral (n = 3312)Not motivated (n = 2173)Total PwO (N = 10,854)
      Mean age, years (range)43 (18–88)45 (18–86)45 (18–87)44 (18–88)
      Gender, n (%)

      Male

      Female

      Other


      2747 (51%)

      2618 (49%)

      4 (< 1%)


      1774 (54%)

      1536 (46%)

      2 (<1%)


      1127 (52%)

      1042 (48%)

      4 (<1%)


      5648 (52%)

      5196 (48%)

      10 (<1%)
      BMI classification for Australia, Chile, Israel, Italy, Mexico, Saudi Arabia, Spain, UAE and UK, n (%)
      Classes I (BMI 30–34.9 kg/m2), II (BMI 35–39.9 kg/m2) and III (BMI ≥40 kg/m2) apply to Australia, Chile, Israel, Italy, Mexico, Saudi Arabia, Spain, the UAE and the UK.


      Obesity Class I (30–34.9 kg/m2)

      Obesity Class II (35–39.9 kg/m2)

      Obesity Class III (≥40 kg/m2)


      2692 (50%)

      861 (16%)

      554 (11%)


      1622 (49%)

      582 (18%)

      336 (11%)


      1021 (48%)

      415 (19%)

      395 (17%)


      5335 (49%)

      1858 (17%)

      1285 (12%)
      BMI classification for Japan and South Korea, n (%)
      Classes 1 (BMI 25–29.9 kg/m2), 2 (BMI 30–34.9 kg/m2), 3 (BMI 35–39.9 kg/m2) and 4 (BMI ≥40 kg/m2) apply to Japan and South Korea.


      Obesity Class 1 (25–29.9 kg/m2)

      Obesity Class 2 (30–34.9 kg/m2)

      Obesity Class 3 (35–39.9 kg/m2)

      Obesity Class 4 (≥40 kg/m2)


      976 (19%)

      193 (3%)

      53 (1%)

      40 (1%)


      600 (18%)

      108 (3%)

      31 (1%)

      33 (1%)


      266 (13%)

      41 (1%)

      14 (1%)

      21 (1%)


      1842 (17%)

      342 (3%)

      98 (1%)

      94 (1%)
      ≥5% weight loss in past 3 years, maintained for ≥1 year, n (%)696 (13%)318 (10%)196 (9%)1210 (11%)
      ≥10% weight loss in past 3 years, maintained for ≥1 year, n (%)400 (7%)155 (4%)85 (4%)640 (6%)
      Numbers are reported for the final unweighted sample; percentages for demographic data are unweighted; percentages for BMI and 5% weight loss are weighted to demographic targets.
      BMI, body mass index; PwO, people with obesity.
      a Classes I (BMI 30–34.9 kg/m2), II (BMI 35–39.9 kg/m2) and III (BMI ≥40 kg/m2) apply to Australia, Chile, Israel, Italy, Mexico, Saudi Arabia, Spain, the UAE and the UK.
      b Classes 1 (BMI 25–29.9 kg/m2), 2 (BMI 30–34.9 kg/m2), 3 (BMI 35–39.9 kg/m2) and 4 (BMI ≥40 kg/m2) apply to Japan and South Korea.
      Fig. 1
      Fig. 1Variables significantly associated with PwO reporting they are motivated to lose weight.a
      CI, confidence interval; HCP, healthcare professional; PwO, people with obesity.
      aVariables associated with a non-significant effect on PwO self-reported feelings of motivation to lose weight are provided in the Appendix.
      bThe option of ‘Internal Medicine Physician’ was not displayed for Chile and the UK.
      PwO who acknowledged that their HCP had a responsibility to actively contribute to a successful weight loss effort, who reported feeling comfortable talking about their weight with their HCP, and who regarded their HCP as a source of information for managing their weight, were more likely to consider themselves as motivated, increasing the odds by a factor of 2.32 (95% CI, 1.86–2.88), 1.46 (95% CI, 1.24–1.72) and 1.36 (95% CI, 1.17–1.58), respectively. When asked which types of HCPs with whom PwO have discussed or would consider discussing their weight, those who selected ‘Internal Medicine Physician’ (in countries where this was provided as an option in the survey) were more likely to report feeling motivated (odds ratio [OR] 1.77; 95% CI, 1.35–2.32) versus not motivated.
      The odds of feeling motivated to lose weight were increased if PwO agreed it was easy for them to lose weight (OR 1.73; 95% CI, 1.30–2.31) and if they lost weight it would be easy for them to keep the weight off (OR 1.77; 95% CI, 1.47–2.14). Agreeing that they know how to lose weight and know how to keep the weight off had a meaningful impact on the odds of PwO feeling motivated, increasing them by 1.36 (95% CI, 1.15–1.62) and 1.38 (95% CI, 1.15–1.65), respectively. Selecting the following goals as an important part of weight management also increased the odds of PwO reporting they were motivated to lose weight: losing a pre-specified number on the scale (OR 1.60; 95% CI, 1.25–2.04) or percentage of their body weight (OR 1.51; 95% CI, 1.23–1.86), or reducing the risks associated with excess weight or preventing a health condition (OR 1.45; 95% CI, 1.22–1.73).
      When PwO agreed that their weight loss is completely their responsibility it increased the odds of feeling motivated versus not motivated by a factor of 1.66 (95% CI, 1.38–2.01). When PwO selected “encouragement and support from others who are trying to lose weight” as having motivated them the most to lose weight, there was a meaningful impact on the odds of reporting themselves to be motivated to lose weight, increasing them by a factor of 1.55 (95% CI, 1.11–2.16).
      PwO who agreed that no matter what they do or how hard they try, they just can't seem to overcome their weight issues were less likely to report feeling motivated versus not motivated, with an OR of 0.66 (95% CI, 0.56–0.78). If PwO thought that obesity is less important than other diseases the odds were also decreased by a factor of 0.49 (95% CI, 0.41–0.58) for motivated versus not motivated.
      A greater proportion of PwO who reported being motivated to lose weight versus not motivated had experienced a 5% or 10% weight loss in the past 3 years that was maintained for at least 1 year, but there were PwO in the not motivated group who had also experienced a successful response to weight loss per these criteria (Table 1).

      3.2 Response to weight loss efforts

      While significant results were found, the models for determining variables associated with at least a 5% or 10% reduction in weight during the past 3 years, maintained for at least 1 year, did not meet the minimum thresholds for statistical reliability. Therefore, confidence in the results was low and no clear trend existed for differentiating successful responses to weight loss efforts from unsuccessful ones.

      4. Discussion

      These regression analyses aimed to determine the attitudes and behaviours of PwO associated with motivation for weight loss. Only half of PwO reported they were motivated to lose weight, highlighting the need to improve overall motivation to facilitate engagement with HCPs and adherence to weight management plans. Since PwO may go through periods of motivation and amotivation, support to both induce and maintain the motivation is required. In this study, level of exercise, which could be considered a motivational measure, was indeed associated with PwO motivation for weight loss. Other variables associated with the likelihood of PwO reporting that they were motivated to lose weight at the time of the survey fell broadly into three key themes: positive HCP interactions, self-efficacy, and weight loss goals.

      4.1 Positive HCP interactions

      PwO who acknowledged their HCP's responsibility to contribute to their weight loss efforts felt comfortable talking about their weight with their HCP, and who regarded their HCP as a source of information for managing their weight were more likely to report feeling motivated than not motivated. It would be interesting to determine if there are particular HCP approaches, such as empathy, that encourage PwO to feel comfortable discussing their weight and to seek HCP advice. Empathy is used in motivational interviewing, which has been suggested to enhance weight loss outcomes [
      • Armstrong M.J.
      • Mottershead T.A.
      • Ronksley P.E.
      • Sigal R.J.
      • Campbell T.S.
      • Hemmelgarn B.R.
      Motivational interviewing to improve weight loss in overweight and/or obese patients: a systematic review and meta-analysis of randomized controlled trials.
      ,
      • Barnes R.D.
      • Ivezaj V.
      A systematic review of motivational interviewing for weight loss among adults in primary care.
      ]. Other studies have demonstrated the importance of active intervention from HCPs. Following referral to a weight management group and offer of follow-up, PwO were more likely to take effective weight management action compared with control participants who were advised that their health would benefit from weight loss [
      • Aveyard P.
      • Lewis A.
      • Tearne S.
      • et al.
      Screening and brief intervention for obesity in primary care: a parallel, two-arm, randomised trial.
      ]. In another study, PwO who had a weight loss of ≥10% over the past 3 years, versus those who did not, were more likely to have previously had weight loss discussions with their HCP and be diagnosed with obesity [
      • Look M.
      • Kolotkin R.L.
      • Dhurandhar N.V.
      • Nadglowski J.
      • Stevenin B.
      • Golden A.
      Implications of differing attitudes and experiences between providers and persons wth obesity: results of the national ACTION study.
      ]. Given the adverse health effects from overweight and obesity [
      GBD 2015 Obesity Collaborators
      Health effects of overweight and obesity in 195 countries over 25 years.
      ], appropriate and regular HCP support is important to help with weight management and prevent or treat the complications of obesity.

      4.2 Self-efficacy

      Reporting finding weight loss easy and weight loss maintenance easy and knowing how to lose weight and how to keep the weight off, increased the odds of feeling motivated to lose weight. In contrast, PwO who reported not being able to overcome their weight issues no matter what they do or how hard they try were less likely to report feeling motivated. Therefore, self-efficacy appears to be a key factor in feeling motivated to lose weight, whereas a sense of failure and hopelessness can negatively impact motivation for weight loss. These feelings could be influenced by weight management history, for example, PwO who believe it is easy to lose weight may have the necessary tools for weight control, had successful weight loss responses previously and less experience of weight regain. These findings highlight the importance of identifying PwO who are struggling to lose weight and ensuring they receive the support, guidance, and treatment options they need. Evaluation of a patient's determination, as part of the self-determination theory, may also help in identifying those who have the tools for weight management and those who need additional support [
      • Teixeira P.J.
      • Sliva M.N.
      • Mata J.
      • Palmeira A.L.
      • Markland D.
      Motivation, self-determination, and long-term weight control.
      ]. Widespread education about the biology of obesity to increase public understanding will also be important for decreasing stigma and fostering a supportive society [
      • Puhl R.M.
      • Heuer C.A.
      Obesity stigma: important considerations for public health.
      ,
      • Alberga A.S.
      • Edache I.Y.
      • Forhan M.
      • Russell-Mayhew S.
      Weight bias and health care utilization: a scoping review.
      ,
      • Phelan S.M.
      • Burgess D.J.
      • Yeazel M.W.
      • Hellerstedt W.L.
      • Griffin J.M.
      • van Ryn M.
      Impact of weight bias and stigma on quality of care and outcomes for patients with obesity.
      ]. Interestingly, PwO who reported that their weight loss was completely their responsibility were also more likely to report feeling motivated to lose weight. It could be speculated that PwO who report being motivated and are taking steps to lose weight feel a sense of responsibility for their weight loss. These PwO may also have the opportunity and capability to achieve behavioural change [
      • Michie S.
      • van Stralen M.M.
      • West R.
      The behaviour change wheel: a new method for characterising and designing behaviour change interventions.
      ]. This sense of responsibility, combined with appropriate support from an HCP, could increase motivation to lose weight. However, self-responsibility could also be a barrier to initiating weight management conversations with HCPs, emphasising the importance of HCPs initiating these discussions in a sensitive and non-judgemental manner.

      4.3 Weight loss goals

      Having goals to lose a pre-specified percentage of body weight or pre-specified number on the scale increased the odds of PwO reporting they are motivated to lose weight. Encouragement from HCPs to set such targets may help with patient motivation to lose weight. However, it may be that PwO reporting they are motivated are more likely to visit their HCP and agree on goal setting. Such targets should be realistic, achievable and adjustable, to avoid the negative impact from feelings of self-blame and failure [
      • Caterson I.D.
      • Alfadda A.A.
      • Auerbach P.
      • et al.
      Gaps to bridge: misalignment between perception, reality and actions in obesity.
      ,
      • Bocquier A.
      • Verger P.
      • Basdevant A.
      • et al.
      Overweight and obesity: knowledge, attitudes, and practices of general practitioners in France.
      ]. Moreover, unrealistic weight loss goals are associated with participant drop-out from weight loss treatment; in one study, the risk of treatment attrition at 12 months increased by 12% for every unit increase in expected BMI loss (p = 0.0018) [
      • Dalle Grave R.
      • Calugi S.
      • Molinari E.
      • et al.
      Weight loss expectations in obese patients and treatment attrition: an observational multicenter study.
      ]. Goals may also focus on specific targets associated with dietary intake or physical activity instead of weight loss per se [
      • Kelley C.P.
      • Sbrocco G.
      • Sbrocco T.
      Behavioral modification for the management of obesity.
      ,
      • Foster G.D.
      • Makris A.P.
      • Bailer B.A.
      Behavioral treatment of obesity.
      ]. Reducing the health risks associated with excess weight or preventing a health condition was another goal associated with motivation and could be incorporated into HCP–patient discussions. In contrast, PwO who considered obesity as less important to them than other diseases were more likely to report feeling not motivated than motivated. PwO who were motivated the most to lose weight by “encouragement and support from others who are trying to lose weight” were also more likely to feel motivated to lose weight. This is consistent with studies showing that group-based obesity interventions can be more effective than individual-based interventions [
      • Paul-Ebhohimhen V.
      • Avenell A.
      A systematic review of the effectiveness of group versus individual treatments for adult obesity.
      ,
      • Rodriguez-Cristobal J.J.
      • Alonso-Villaverde C.
      • Panisello J.M.
      • et al.
      Effectiveness of a motivational intervention on overweight/obese patients in the primary healthcare: a cluster randomized trial.
      ]. Experts have also noted the importance of family support [
      • Gruber K.J.
      • Haldeman L.A.
      Using the family to combat childhood and adult obesity.
      ].
      The data for the group of PwO who provided a neutral response largely fell between the data for the motivated and not motivated groups, showing that motivation is not dichotomous. Of note, motivation was not strongly associated with 3-year weight loss outcomes, suggesting that levels of motivation may instead reflect the same stage of the weight management cycle. In this cycle, PwO make weight loss efforts, lose weight, maintain the weight loss for a period, then due to biological adaptations, regain weight [
      • MacLean P.S.
      • Higgins J.A.
      • Giles E.D.
      • Sherk V.D.
      • Jackman M.R.
      The role for adipose tissue in weight regain after weight loss.
      ]. Previous studies have demonstrated an association between weight management and the importance of internal motivation factors to lose weight [
      • Elfhag K.
      • Rössner S.
      Who succeeds in maintaining weight loss? A conceptual review of factors associated with weight loss maintenance and weight regain.
      ,
      • Soini S.
      • Mustajoki P.
      • Eriksson J.G.
      Long-term weight maintenance after successful weight loss: motivational factors, support, difficulties, and success factors.
      ]. It has been noted that PwO who are motivated to lose weight may attempt weight loss efforts multiple times, which can lead to successful weight loss and long-term weight maintenance with limited weight cycling [
      • Dandanell S.
      • Ritz C.
      • Verdich E.
      • Dela F.
      • Helge J.W.
      Repeated lifestyle interventions lead to progressive weight loss: a retrospective review chart study.
      ]. Therefore, keeping PwO motivated is encouraged to help support long-term weight maintenance and improved health outcomes [
      • Dandanell S.
      • Ritz C.
      • Verdich E.
      • Dela F.
      • Helge J.W.
      Repeated lifestyle interventions lead to progressive weight loss: a retrospective review chart study.
      ].
      It should be noted that causation between the self-reported factors cannot be determined from this study; however, these data provided insights into factors that are associated with PwO feelings of motivation at the time of the survey. Due to the self-reported nature of the study, the results can only convey data for PwO who say they are motivated, rather than having an independent measure of motivation. Moreover, motivation was assessed by a single question, the response to which, as with all questions in the survey, could be influenced by the environment and feelings of the PwO at the time of the survey. However, the association between frequency of exercise and motivation suggests that the PwO who reported they are motivated to lose weight were indeed actively taking steps for weight management. Other limitations include the need for internet access in most countries, which may have skewed participation, and reliance on self-reported data. While self-reported height and weight align with measured values in many cases, discrepancies have been identified that generally result in underestimation of BMI for PwO in a proportion of cases [
      • Ng C.D.
      Errors in body mass index from self-reported data by sex and across waves of Add Health.
      ,
      • Wilson O.W.A.
      • Bopp C.M.
      • Papalia Z.
      • Bopp M.
      Objective vs self-report assessment of height, weight and body mass index: relationships with adiposity, aerobic fitness and physical activity.
      ,
      • Blum K.S.
      • Büsch N.
      • Beyer T.
      • Rausch I.
      • Freudenberg L.S.
      In patients we trust: reliability of self-reported weight and height in nuclear medicine patients.
      ,
      • Olfert M.D.
      • Barr M.L.
      • Charlier C.M.
      • et al.
      Self-reported vs. measured height, weight, and BMI in young adults.
      ,
      • Stommel M.
      • Schoenborn C.A.
      Accuracy and usefulness of BMI measures based on self-reported weight and height: findings from the NHANES & NHIS 2001-2006.
      ,
      • Maukonen M.
      • Männistö S.
      • Tolonen H.
      A comparison of measured versus self-reported anthropometrics for assessing obesity in adults: a literature review.
      ,
      • Neermark S.
      • Holst C.
      • Bisgaard T.
      • et al.
      Validation and calibration of self-reported height and weight in the Danish Health Examination Survey.
      ]. Thus, actual BMI measurements could have been slightly higher than those reported.
      A global trend did not exist for differentiating successful responses to weight loss efforts from unsuccessful ones. This finding is in keeping with the general perspective that an individual's weight loss success is driven by a multitude of factors such as environment and culture, genetics, lifestyle, community and the healthcare system. As with any chronic disease, there is heterogeneity in the response to any particular form of treatment. Two PwO may have the same attitudes towards weight loss but encounter completely different cultural, institutional, and personal barriers which ultimately determine their response to treatment. When considering the wide variation in healthcare systems and cultures of the different countries in this study, it may not be surprising that a single unified set of factors associated with successful weight loss outcomes could not be identified at the global level. In the national ACTION study conducted in the Unites States, significant associations between independent variables and maintenance of 10% weight loss for at least 1 year were identified [
      • Dhurandhar N.V.
      • Kyle T.
      • Stevenin B.
      • Tomaszewski K.
      • ACTION Steering Group.
      Predictors of weight loss outcomes in obesity care: results of the national ACTION study.
      ]. PwO who reported being motivated to talk to a diabetes educator about their weight, who had their weight loss efforts recognised by an HCP, and were provided a diagnosis of obesity were more likely to report having successful weight loss outcomes (defined as maintaining 10% weight loss for at least 1 year) [
      • Dhurandhar N.V.
      • Kyle T.
      • Stevenin B.
      • Tomaszewski K.
      • ACTION Steering Group.
      Predictors of weight loss outcomes in obesity care: results of the national ACTION study.
      ]. Therefore, variables associated with successful responses to weight loss efforts might be identified from the ACTION-IO data when studying the different regions and countries.

      5. Conclusions

      Supportive HCP–patient dialogue, preferably initiated by the HCP, that is free of stigma and which incorporates the importance of obesity management for health and the biological basis of the disease is required. This allows for the setting of achievable weight loss targets and the provision of guidance and options to assist with a successful response to the weight loss efforts, which may help with PwO motivation to lose weight. Weight loss in the presence of counteracting biological mechanisms is extremely difficult and proactive support and treatment is required to improve self-efficacy. Recognising PwO characteristics associated with motivation may also identify patients ready for weight management, and appropriate HCP support may facilitate weight loss efforts. Further research is required to determine if strategies for improving response rates to weight loss efforts can be identified on a regional scale.

      Contributors

      All authors contributed to the design of the study. All authors participated in interpretation of the data and drafting and revision of the manuscript. All authors reviewed and approved the final, submitted version.

      Declaration of Competing Interest

      All authors received funding for travel expenses from Novo Nordisk to attend author meetings during the conduct of the study.
      D. D. reports personal fees for medical lectures and consultations from Novo Nordisk during the conduct of the study and personal fees for medical lectures and consultations from Teva Pharmaceutical Industries outside the submitted work; D. D. is a guest Editor of the European Journal of Internal Medicine.
      A. A. A. reports financial support from Novo Nordisk to attend an obesity conference during the conduct of the study, and personal (consultancy) fees and non-financial support from Novo Nordisk outside the submitted work.
      W. C. reports personal (consultancy and speaker) fees from Novo Nordisk, EMS, Germed Pharma and Janssen Pharmaceutica outside the submitted work.
      A. C. reports personal fees from Abbott, Novo Nordisk, Teva Pharmaceutical Industries and Saval Pharmaceuticals during the conduct of the study; she is a member of the Strategic Centre for Obesity Professional Education (SCOPE) of the World Obesity Federation and a SCOPE International Fellow.
      J. H. reports fees (honoraria) paid to the University of Liverpool from Novo Nordisk, Orexigen and Boehringer Ingelheim during the conduct of the study.
      C. A. H. reports financial support from Novo Nordisk to attend an obesity conference during the conduct of the study, grants from the Rona Marsden Fund at Fakenham Medical Practice and personal fees from Alva, Orexigen Therapeutics, Consilient Health, Nestlé and Ethicon outside the submitted work; she was previously a member of the World Obesity education committee, is a current member of the Association for the Study of Obesity (ASO) and is involved in meetings to facilitate recognition of obesity as a disease in the UK.
      M. I. reports receiving non-financial support from Novo Nordisk during the conduct of the study and personal fees from Novo Nordisk outside the submitted work.
      J.-H. K. reports compensation from Novo Nordisk as a consultant during the conduct of the study.
      R. N. reports financial support from Novo Nordisk to attend an obesity conference during the conduct of the study, and personal (consultancy and speaker) fees from Novo Nordisk outside the submitted work.
      R. R. and N. R. are employees of Novo Nordisk, and own shares in Novo Nordisk.
      G. R. reports personal (consultancy) fees and non-financial support from Novo Nordisk during the conduct of the study; personal (consultancy and lecture) fees and non-financial support from Novo Nordisk, iNova Pharmaceuticals, personal (lecture) fees from Johnson & Johnson, mdBriefCase Australia & Global, Medtronic (formerly Covidien), ReShape Lifesciences (formerly Apollo-Endosurgery) outside the submitted work and non-financial support from Device Technologies and W.L. Gore, outside the submitted work.
      J. S. reports personal (consultancy) fees from Novo Nordisk during the conduct of the study.
      P. S. reports personal fees (grants) from Novo Nordisk during the conduct of the study.
      V. V. V. reports personal fees and non-financial support from Novo Nordisk during the conduct of the study.
      I. D. C. reports personal fees from Novo Nordisk (as chair of the ACTION-IO steering committee) during the conduct of the study, grants from Novo Nordisk, Rhythm Pharmaceuticals, and SFI outside the submitted work, and personal (lecture) fees from Novo Nordisk outside the submitted work.

      Acknowledgements

      We gratefully acknowledge the study participants and all personnel involved in the study. We especially thank Chris Claeys, Lynn Clement and Rebecca Hahn of KJT Group for data analysis. This study was sponsored by Novo Nordisk, which also provided financial support for medical editorial assistance from Abbie Saunders, Ph.D., CMPP, of Articulate Science.

      Refereces

        • GBD 2015 Obesity Collaborators
        Health effects of overweight and obesity in 195 countries over 25 years.
        N Engl J Med. 2017; 377: 13-27
        • Guh D.P.
        • Zhang W.
        • Bansback N.
        • Amarsi Z.
        • Laird Birmingham C.
        • Anis A.H.
        The incidence of co-morbidities related to obesity and overweight: a systematic review and meta-analysis.
        BMC Public Health. 2009; 9: 88
        • Djalalinia S.
        • Qorbani M.
        • Peyraki N.
        • Kelishadi R.
        Health impacts of obesity.
        Pak J Med Sci. 2015; 31: 239-242
        • van der Klaauw A.A.
        • Farooqi I.S.
        The hunger genes: pathways to obesity.
        Cell. 2015; 161: 119-132
        • Puhl R.M.
        • Heuer C.A.
        Obesity stigma: important considerations for public health.
        Am J Public Health. 2010; 100: 1019-1028
        • Honce R.
        • Schultz-Cherry S.
        Impact of obesity on influenza A virus pathogenesis, immune response, and evolution.
        Front Immunol. 2019; 10: 1071
        • Kassir R.
        Risk of COVID-19 for patients with obesity.
        Obes Rev. 2020; 21: e13034
        • Kass D.A.
        • Duggal P.
        • Cingolani O.
        Obesity could shift severe COVID-19 disease to younger ages.
        Lancet. 2020; 395: 1544-1545
        • Caussy C.
        • Pattou F.
        • Wallet F.
        • et al.
        Prevalence of obesity among adult inpatients with COVID-19 in France.
        Lancet Diabetes Endocrinol. 2020; 8: 562-564
        • Lemstra M.
        • Bird Y.
        • Nwankwo C.
        • Rogers M.
        • Moraros J.
        Weight loss intervention adherence and factors promoting adherence: a meta-analysis.
        Patient Prefer Adherence. 2016; 10: 1547-1559
        • Caterson I.D.
        • Alfadda A.A.
        • Auerbach P.
        • et al.
        Gaps to bridge: misalignment between perception, reality and actions in obesity.
        Diabetes Obes Metab. 2019; 21: 1914-1924
        • Webber K.H.
        • Tate D.F.
        • Ward D.S.
        • Bowling J.M.
        Motivation and its relationship to adherence to self-monitoring and weight loss in a 16-week internet behavioral weight loss intervention.
        J Nutr Educ Behav. 2010; 42: 161-167
        • Brantley P.J.
        • Stewart D.W.
        • Myers V.H.
        • et al.
        Psychosocial predictors of weight regain in the weight loss maintenance trial.
        J Behav Med. 2014; 37: 1155-1168
        • Leibel R.L.
        • Rosenbaum M.
        • Hirsch J.
        Changes in energy expenditure resulting from altered body weight.
        N Engl J Med. 1995; 332: 621-628
        • Sumithran P.
        • Prendergast L.A.
        • Delbridge E.
        • et al.
        Long-term persistence of hormonal adaptations to weight loss.
        N Engl J Med. 2011; 365: 1597-1604
        • Ghanemi A.
        • Yoshioka M.
        • St-Amand J.
        Broken energy homeostasis and obesity pathogenesis: the surrounding concepts.
        J Clin Med. 2018; 7: 453
      1. International Association for the Study of Obesity (IASO). The asia-pacific perspective: redefining obesity and its treatment. https://apps.who.int/iris/bitstream/handle/10665/206936/0957708211_eng.pdf?sequence=1&isAllowed=y. February 2000.

      2. The R Foundation. R: a language and environment for statistical computing. 2020. https://www.R-project.org/.

        • Scheipl F.
        spikeSlabGAM: bayesian Variable Selection, Model Choice and Regularization for Generalized Additive Mixed Models in R.
        J Stat Softw. 2011; 43https://doi.org/10.18637/jss.v043.i14
        • Armstrong M.J.
        • Mottershead T.A.
        • Ronksley P.E.
        • Sigal R.J.
        • Campbell T.S.
        • Hemmelgarn B.R.
        Motivational interviewing to improve weight loss in overweight and/or obese patients: a systematic review and meta-analysis of randomized controlled trials.
        Obes Rev. 2011; 12: 709-723
        • Barnes R.D.
        • Ivezaj V.
        A systematic review of motivational interviewing for weight loss among adults in primary care.
        Obes Rev. 2015; 16: 304-318
        • Aveyard P.
        • Lewis A.
        • Tearne S.
        • et al.
        Screening and brief intervention for obesity in primary care: a parallel, two-arm, randomised trial.
        Lancet. 2016; 388: 2492-2500
        • Look M.
        • Kolotkin R.L.
        • Dhurandhar N.V.
        • Nadglowski J.
        • Stevenin B.
        • Golden A.
        Implications of differing attitudes and experiences between providers and persons wth obesity: results of the national ACTION study.
        Postgrad Med. 2019; 131: 357-365
        • Teixeira P.J.
        • Sliva M.N.
        • Mata J.
        • Palmeira A.L.
        • Markland D.
        Motivation, self-determination, and long-term weight control.
        Int J Behav Nutr Phys Act. 2012; 9: 22
        • Alberga A.S.
        • Edache I.Y.
        • Forhan M.
        • Russell-Mayhew S.
        Weight bias and health care utilization: a scoping review.
        Prim Health Care Res Dev. 2019; 20: e116
        • Phelan S.M.
        • Burgess D.J.
        • Yeazel M.W.
        • Hellerstedt W.L.
        • Griffin J.M.
        • van Ryn M.
        Impact of weight bias and stigma on quality of care and outcomes for patients with obesity.
        Obes Rev. 2015; 16: 319-326
        • Michie S.
        • van Stralen M.M.
        • West R.
        The behaviour change wheel: a new method for characterising and designing behaviour change interventions.
        Implement Sci. 2011; 6: 42
        • Bocquier A.
        • Verger P.
        • Basdevant A.
        • et al.
        Overweight and obesity: knowledge, attitudes, and practices of general practitioners in France.
        Obes Res. 2005; 13: 787-795
        • Dalle Grave R.
        • Calugi S.
        • Molinari E.
        • et al.
        Weight loss expectations in obese patients and treatment attrition: an observational multicenter study.
        Obes Res. 2005; 13: 1961-1969
        • Kelley C.P.
        • Sbrocco G.
        • Sbrocco T.
        Behavioral modification for the management of obesity.
        Prim Care. 2016; 43: 159-175
        • Foster G.D.
        • Makris A.P.
        • Bailer B.A.
        Behavioral treatment of obesity.
        Am J Clin Nutr. 2005; 82 (Suppl, 230S–235S)
        • Paul-Ebhohimhen V.
        • Avenell A.
        A systematic review of the effectiveness of group versus individual treatments for adult obesity.
        Obes Facts. 2009; 2: 17-24
        • Rodriguez-Cristobal J.J.
        • Alonso-Villaverde C.
        • Panisello J.M.
        • et al.
        Effectiveness of a motivational intervention on overweight/obese patients in the primary healthcare: a cluster randomized trial.
        BMC Fam Pract. 2017; 18: 74
        • Gruber K.J.
        • Haldeman L.A.
        Using the family to combat childhood and adult obesity.
        Prev Chronic Dis. 2009; 6: A106
        • MacLean P.S.
        • Higgins J.A.
        • Giles E.D.
        • Sherk V.D.
        • Jackman M.R.
        The role for adipose tissue in weight regain after weight loss.
        Obes Rev. 2015; 16 (Suppl 1Suppl): 45-54
        • Elfhag K.
        • Rössner S.
        Who succeeds in maintaining weight loss? A conceptual review of factors associated with weight loss maintenance and weight regain.
        Obes Rev. 2005; 6: 67-85
        • Soini S.
        • Mustajoki P.
        • Eriksson J.G.
        Long-term weight maintenance after successful weight loss: motivational factors, support, difficulties, and success factors.
        Am J Health Behav. 2018; 42: 77-84
        • Dandanell S.
        • Ritz C.
        • Verdich E.
        • Dela F.
        • Helge J.W.
        Repeated lifestyle interventions lead to progressive weight loss: a retrospective review chart study.
        Scand J Public Health. 2017; 45: 305-313
        • Ng C.D.
        Errors in body mass index from self-reported data by sex and across waves of Add Health.
        Ann Epidemiol. 2019; 39: 21-25
        • Wilson O.W.A.
        • Bopp C.M.
        • Papalia Z.
        • Bopp M.
        Objective vs self-report assessment of height, weight and body mass index: relationships with adiposity, aerobic fitness and physical activity.
        Clin Obes. 2019; 9: e12331
        • Blum K.S.
        • Büsch N.
        • Beyer T.
        • Rausch I.
        • Freudenberg L.S.
        In patients we trust: reliability of self-reported weight and height in nuclear medicine patients.
        J Nucl Med Technol. 2019; 47: 133-136
        • Olfert M.D.
        • Barr M.L.
        • Charlier C.M.
        • et al.
        Self-reported vs. measured height, weight, and BMI in young adults.
        Int J Environ Res Public Health. 2018; 15: 2216
        • Stommel M.
        • Schoenborn C.A.
        Accuracy and usefulness of BMI measures based on self-reported weight and height: findings from the NHANES & NHIS 2001-2006.
        BMC Public Health. 2009; 9: 421
        • Maukonen M.
        • Männistö S.
        • Tolonen H.
        A comparison of measured versus self-reported anthropometrics for assessing obesity in adults: a literature review.
        Scand J Public Health. 2018; 46: 565-579
        • Neermark S.
        • Holst C.
        • Bisgaard T.
        • et al.
        Validation and calibration of self-reported height and weight in the Danish Health Examination Survey.
        Eur J Public Health. 2019; 29: 291-296
        • Dhurandhar N.V.
        • Kyle T.
        • Stevenin B.
        • Tomaszewski K.
        • ACTION Steering Group.
        Predictors of weight loss outcomes in obesity care: results of the national ACTION study.
        BMC Public Health. 2019; 19: 1422