When asked to explain their inability to lose weight, bariatric surgery candidates most frequently cited nonspecific reasons related to diet, physical activity, and motivation/self-control/will power. They rarely cited time, financial cost, social support, physical environment, or knowledge as factors. Men gave explanations related to medical conditions or medications more often than women, but women were more likely to give explanations related to diet.
The main strength of the study is that we analyzed a large sample with a combined qualitative and quantitative approach. Our findings present the perspective of individuals who have had the greatest difficulty in losing weight.
The study was limited by the retrospective, single-center design. Another limitation is that the two most common explanations for unsuccessful weight loss were nonspecific statements related to diet and physical activity without further elaboration. We cannot determine if the respondents were unaware of reasons for dietary or physical activity difficulties or if they simply did not mention them. An additional limitation is the moderate response rate. Differences between responders and nonresponders in BMI and race/ethnicity were statistically significant but of unknown clinical significance.
Other analyses of bariatric surgery candidates have focused on psychosocial and behavioral characteristics to predict postoperative outcomes. A common area of investigation is the control of eating behavior. Many bariatric surgery candidates have high levels of hunger and low levels of dietary restraint [19
]. The prevalence of specific eating disorders, such as binge eating disorder and nighttime eating syndrome, ranges from 10% to 50% [19
]. These constructs may be related to our category of motivation/self-control/will power, but prior studies reported prevalence, rather than whether patients thought these factors contributed to their obesity. Many individuals seeking bariatric surgery also have psychiatric conditions such as depression and anxiety, but it is unclear whether these disorders cause or are caused by obesity [19
]. We have no reason to believe that the prevalence of psychiatric problems in our subjects was different than in other samples, but our subjects rarely (2.9%) cited psychiatric disorders to explain their inability to lose weight.
Subjective barriers to weight loss have been reported for other populations. In focus groups, obese African-American women cited ethnic and cultural norms, influence of close family members, food cravings, as well as lack of time, resources, self-control, and social support [11
], obese Caucasian women reported depression and lack of commitment to diet [11
], and overweight men discussed inadequate motivation and negative perception of dieting [12
]. In a national survey of US adults, barriers to weight loss included inadequate energy (65%), will power (56%), time (44%), and social support (38%) for exercise, as well as high cost of healthy food (49%), preference for junk food (48%), and eating out (40%) [13
]. Patients at a Veteran’s Administration clinic believed that excess weight was caused by easy access to fattening foods (73%) and medical conditions (70%) [7
]. Differences in prevalence of weight loss barriers are likely due to different study samples and designs.
By the time obese individuals seek bariatric surgery, they are unlikely to lose significant weight with behavioral changes alone [21
]. However, our findings can suggest targets for earlier intervention. The first target is a redistribution of responsibility. Our subjects cited difficulties with diet, physical activity, and motivation/self-control/will power in comparable proportions, such that clinicians focusing on any single element to the exclusion of others will not meet the stated needs of a significant portion of their obese patients. This reinforces current recommendations that clinicians offer a comprehensive approach to obesity treatment, rather than focus on any single issue with which they are most comfortable [1
]. Given that primary care providers typically lack the time and skills to provide comprehensive obesity management [23
], a division of labor is needed in which specialized personnel (e.g., dietitians, fitness professionals, health counselors) provide behavioral weight loss services as part of a comprehensive program [27
]. Implementing this model of care would require shifting focus from training primary care providers to become weight loss counselors to incorporating specialized weight loss counselors into the primary care team [30
]. It also follows that the same comprehensive approach should be offered to patients after bariatric surgery.
The second potential target for earlier intervention is that which our subjects did not
mention. They rarely cited the physical environment or social support as factors in their inability to lose weight. Yet, the wide availability of high-calorie foods and surroundings that discourage physical activity create an obesogenic environment [33
]. Specific aspects of the physical environment associated with obesity include suburban location (vs urban), disorderly surroundings (e.g., litter, graffiti, vandalism), lack of destinations within a 10-min walk from home, lack of interesting things to look at, and limited access to physical activity or recreational facilities [36
]. Interpersonal relationships within social networks can also impact body weight. Findings from a 32-year cohort study provide compelling evidence for the spread of obesity through social networks, possibly mediated by the adoption of norms for body weight and behavior [38
]. Conversely, access to purposeful social support is directly correlated with the ability to lose weight and maintain weight loss [1
]. It is unlikely that our subjects were immune to the influence of the physical and social environment. An alternative hypothesis is that they did not recognize the effect of these factors. To test this hypothesis, future studies could explicitly ask obese individuals how they perceive the influence of the built environment and social networks on their body weight. The research agenda can be extended to evaluate whether obese individuals can be taught to identify and actively resist harmful environmental and social influences and whether such efforts will facilitate weight loss.
Lastly, our results suggest that clinicians should anticipate gender differences when discussing weight loss with patients. Men were more likely than women to explain unsuccessful weight loss by citing medical conditions that affect physical activity (e.g., arthritis), but women were more likely than men to cite diet-related explanations. In other studies, women were more likely than men to report cravings for sweets [43
] and difficulty in controlling eating habits [44
] and to attribute being overweight to overeating [45
]. Among bariatric surgery candidates, women are more likely to have attempted weight loss through dietary modification [21
]. Anticipating gender differences in how patients view their weight problem might guide the assessment process and facilitate treatment tailoring.
In this study, we sought to understand how bariatric surgery candidates explained their inability to lose weight. Our results suggest that clinicians, with or without the help of specialized personnel, should offer a comprehensive approach to address the stated needs of obese patients, raise awareness among patients about the pervasive yet under-recognized impact of the physical environment and social interactions on body weight, and anticipate gender differences in how patients view their weight problem. Further study is needed to specifically test these exploratory findings.