This study utilized open-ended questions to identify reasons as to why a patient with obesity who enrolled in a hospital-based WMP wanted to lose weight. The four emerging themes are health, function, appearance and perceived stigma.
This study found ‘health’ as the patients’ motivator to lose weight, evident across both genders and all age groups. This finding is similar to a few other studies that looked into the reasons and motivations to losing weight (11–13). The respondents to those studies overwhelmingly ranked ‘health’ as their most common reason as well.
Notably, improving one’s general health is driven by wanting to be healthy for one’s self, to practice healthy living and concerns over existing diseases and health risks. Our findings are also similar to the main motivations described by patients among Canadian adults who were trying to lose weight. The study found that common reasons to lose weight include reducing risk for heart disease (11), a similar concern shared by our patients. The goal of weight reduction to reduce the risk of cardiovascular disease needs to be understood by both, patients, and health care providers. A weight reduction of 5% is needed among obese or overweight adults for a significant reduction in all cardiovascular risks (29). These findings may have practical implications for health care providers in addressing concerns and setting up appropriate weight loss goals in achieving the desired reduction in cardiovascular risks.
Other important reasons to lose weight were described as health rewards and psychological rewards. Health rewards include the intention to improve health for the sake of fertility. Women who wanted to improve fertility were young females, at the age when the impact of obesity on fertility is at its greatest (30) and weight loss before assisted reproductive treatment can significantly improve pregnancy outcome (31). However, motivation to lose weight for improved fertility contradicts that of Sacha et al, which found that overweight and obese women presented with infertility at an academic fertility centre were unwilling to delay their fertility treatment while attempting to lose weight (32). The difference in urgency the for fertility treatment could be explained by the difference in the BMI categories between the study patients. Our study had more severely obese patients with a higher mean of BMI, explaining why fertility was considered highest in priority as a reason to lose weight as compared to patients in overweight category.
Two patients highlighted gaining health rewards to proceed with organ transplantation. A similar motivation was observed in a study among severely obese patients who needed to qualify for renal transplant (33). This motivation is evident by the high stake procedure in which the health reward for weight loss is the prolonging of life itself. While patients in our study did not specify details on the type of organ transplantation, studies have shown that pre-transplantation weight loss among obese patients can improve recovery outcome and survival (34, 35). This finding suggests that patients, who are planning for a time-sensitive medical treatment, they must maintain a high motivation to lose weight and would need an intensive level of support to achieve their optimum weight within a crucial time limit.
With regards to psychological reward, some patients expressed their reason was the desire to increase their level of self-esteem and self-confidence. Other studies share this finding with patients of varying ages (13, 36) suggesting that self-confidence is a common motivator for weight loss across all age groups. Successful weight loss, in turn, can increase self-confidence (37). Their need for increased self-confidence could infer that the presence of psychological support to supplement the need for psychological well-being would be an added advantage in WMP.
For the theme ‘function’, it was inferred by both male and female patients equally. The inference was observed among those within the young adults and middle-aged adults groups. The subcategory of “to maintain function for self” was mentioned the most. This is not surprising as the presence of medical conditions is prevalent among obese adults, which can impair functional capacity and reduce the quality of life (38, 39). It is endearing to discover that female patients related more to the subcategory “to maintain function to care for family members” as compared to male. Being responsible to look after family members perhaps could related to the ‘sandwich generation’ where working women carry the simultaneous task in caring for their elderly parents as well as young children. In a survey conducted among the Malaysian female government employees, it was found that 66.7% of women were caregivers for either elderly parents or their children and 33.3% provided care to elderly parents and children (40). Perhaps, the additional support of a social worker within the WMP team can be introduced to those who require help during the weight-loss period.
Appearance has been reported as a reason to lose weight (11, 12, 41). Improving appearance was the third theme cited and is more common among the early adolescent age group and female patients. This finding is similar to other studies (11, 12, 13) and a study among high school pupils in German which identified appearance associated with social pressure to be prevalent among adolescents of the age 10 to 16 years old and girls were found to be more affected than the boys (42). In contrast, older adults were the least to infer appearance as their motivator to lose weight. With increasing age, people tend to value health more than appearance (11). Comparable to a study conducted by O’Brien et al, subjects with a mean age of 40-year old and BMI of 34 kg/m2 (12) were less concerned about their appearance as a motivating reason to lose weight.
The theme “perceived stigma” emerged among a small percentage of the patients but was particularly obvious among the early adolescent patients of less than 18 years as compared to the other age groups. A slightly higher percentage of male patients quoted perceived stigma as their reason to lose weight as compared to females. Obesity is a known stigmatizing condition and is associated with psychological problems (43, 44). The idea of stigma being a motivator to lose weight is debatable. Perceived stigma seemed to serve as both a motivator and barrier to weight loss. Our study shared a similar finding to a qualitative study, which found stigmatization as a motivator to lose weight among obese patients (45).
In contrast, other pieces of evidence have found contradictory findings suggesting weight-based stigmatization resulted in unhealthy eating habits and weight gain. For example, in adults, studies have found that instead of losing weight, weight-based stigmatization resulted in binge-eating behaviour (46, 47) while among adolescents, it resulted in binge-eating and unhealthy weight control behaviours (48, 49). A study in the UK looking at the visual representation of obesity in the media found that subjects described as obese tended to represent the higher BMI obese range (50). Since most of the patients in this study are in the severe BMI range of obesity, they truly fit into society’s description of ‘obesity’. Contrary to the findings by these studies, instead of responding to perceived stigma negatively, our patients have cited perceived stigmatization as one of the main reasons as to why they want to lose weight.
There have been suggestions to stigmatize obesity in the effort to encourage people to lose weight and using weight stigma as a public health tool (51–53). Stigma based campaigns have been successful in dealing with other health issues such as smoking but there is little evidence to show that stigmatizing obesity promotes weight loss. As discussed, studies have found that stigmatizing obesity can result in a high degree of psychological stress (54) which in turn promote unwanted coping responses by eating more food and refusing to lose weight and consequently, could lead to more weight gain (55, 56). Therefore, it seems unethical to use stigma weight campaign, which potentially can exert a negative impact on obese subjects in their weight loss journey.
The strength of this study is that it provided data from a sample that has not been commonly studied. The sample represents patients attending hospital-based, multidisciplinary team WMP in Malaysia. Majority of the patients were morbidly obese with BMI of more than 40 kg/m2. However, this also serves as a limitation since it is a hospital-based setting with mainly morbidly obese subjects. Therefore, the results cannot be generalized to other overweight and obese population.
Additionally, the limitations include that the survey question was an open-ended self-administered question and are therefore, no further clarifications with probing was able to be conducted to capture the exact reasons identified by patients. The use of the question "What is the main factor why you want to lose your weight' may limit patients' responses, especially when they have more than one main reason. However, many patients responded with several reasons to lose weight. Some of the patients may have more than one main reason to lose weight and were not captured by this survey. Therefore, future follow-up study with in-depth interviews is recommended to examine the underlying ideas, assumptions, and conceptualizations related to the reasons to lose weight within this population.