Weight maintenance remains to be a challenge for patients in a reduced obese state and it has been recommended to provide them more individualized support. For this purpose it is crucial to understand the barriers patients are experiencing after weight loss. Many have been identified by qualitative studies. We evaluated if a quantitative assessment of patient perspective during weight maintenance can help identify major barriers that refer to actual regain.
Follow-up data were analyzed from patients attempting weight maintenances after successful completion of a nonsurgical weight loss and lifestyle intervention for morbid obesity. The data were acquired at mandatory follow-up assessments and included rating of 26 probable difficulties. A principal component analysis was carried out to explore whether these difficulties could be grouped into meaningful factors. Associations with socio-demographics, follow-up time, and weight changes were evaluated.
Data from 88 out of 102 patients were available (baseline BMI 49.5 ± 7.4 kg/m2; 12-month weight loss 24.3 ± 9.6%; follow-up time 1.48 ± 0.6 years). Four solid factors, composed of 21 items and explaining 56% of the variance were extracted and interpreted as ‘Hedonic Hunger’, ‘Mental Distress’, ‘Binge Eating’, and ‘Demoralization’. Weight regain (12.4 ± 12%) was correlated with each factor, most closely with ‘Mental Distress’ (r = 0.38). When controlling for age and follow-up time, ‘Binge Eating’ was the most important predictor (adj. R2 = 0.297).
A quantitative assessment of patient perspective during the first years after weight loss can help identify valid barriers to weight loss maintenance.
Obesity has become a challenge and burden for health care systems all over the world. Standard treatment comprises surgical and lifestyle interventions, both of which can initiate a weight loss episode that leads to improvement of many comorbidities . However, after reaching nadir weight an opposing episode follows that is typically characterized by gradual weight regain [2,3,4]. In the past years, more information has been revealed with respect to this episode, suggesting that its onset is related to physiological adaptations rather than to the modalities of the initial weight lost [5, 6]. Thus, weight maintenance can be considered a challenge for every patient who is in a reduced obese state .
Despite its strong biological determination, a considerable number of patients are able to minimize weight regain . This has been attributed to a set of behavioral and psychological determinants [9,10,11]. However, weight maintenance intervention studies reported mainly disappointing results [8, 12]. An increase of physical activity and exercise, for example, is clearly predictive of weight loss maintenance, but when applied as a clinical intervention in randomized controlled trials its effectiveness remains questionable [11, 13].
The National Institutes of Health have recently recommended that patients struggling with weight regain should therefore be provided with a more individualized and targeted strategy . To offer such strategies it is crucial to identify the relevant barriers patients experience during weight maintenance . However, many studies assessed psychological barriers only indirectly by utilizing weight-unspecific questionnaires of concepts such as stress, depression, or disinhibition , and those that directly investigated patient perspective either relied on qualitative assessments, had limited follow-up rates, or lacked objective weight data [15,16,17]. To the best of our knowledge, patient perspective on weight loss maintenance difficulties has not yet been evaluated quantitatively, probably because it is challenging to recruit comprehensive follow-up samples after weight loss.
At our clinic, we have successfully established an intensified nonsurgical weight loss and lifestyle intervention for morbidly obese patients that fosters follow-up rates by comprising mandatory follow-up evaluations . Our aim was to use this comprehensive data to assess the frequency of difficulties experienced during the first three, most critical years after treatment completion [19, 20] and to evaluate if main barriers to weight loss maintenance can be extracted quantitatively from it. We also wanted to evaluate if the barriers identified in the present sample relate to the amount of weight regained.
Materials and methods
The present paper reports data from an ongoing observational study that was designed to prospectively evaluate a publicly available, nonsurgical weight loss treatment program for patients with morbid obesity. It comprises a 12-month multidisciplinary lifestyle intervention with a very low-calorie diet, a 5-year follow-up care with mandatory annual checkups, and a prospective evaluation and was established after approval by the Ethical Review Board of the Saxonian Medical Association (EK-B-07/10-1) . Written informed consent was taken from every patient prior to inclusion. The observational period for the present report lasted from June 2013 to February 2017.
Inclusion criteria for the treatment program comprised of an age between 18 and 70 years, a BMI ≥ 35 kg/m2 with associated comorbidities, or a BMI ≥ 40 kg/m2. Exclusion criteria were bedridden status, cardiac or pulmonary insufficiency, malignant disease, pregnancy or lactation, binge eating disorder or other severe, unstable, or untreated mental disorders. For the present report, data from all patients were considered who met the following criteria at the time of data analysis: (1) completion of the 12-month therapy, (2) relative weight loss >5% after 12 months, and (3) follow-up time >9 months. Out of 132 patients who had been included into the treatment, 104 completed the 12-month program (i.e., 28 dropped out) and 102 achieved a weight loss of >5%.
After treatment completion, a structured follow-up care is provided that includes annual checkups at the treatment center for monitoring of disease progression and providing individualized recommendations. In the present report, data from the most recent checkup of each patient was analyzed. Body weight was assessed by using a Kern MTS 300 K 100 M scale (Kern and Sohn GmbH, Balingen, Germany). Current weight maintenance difficulties were assessed by using a list of 26 probable difficulties which were rated on a five-point Likert scale with the option to describe additional difficulties (Table 2). This list was put together by experienced staff from the obesity treatment center and reviewed by members of the “patient board”, a group of patients that came together to represent the interests of all patients battling weight regain during follow-up care. At first, the members of the multiprofessional team (i.e., one nutritionist, two clinical psychologists, one specialist for nutritional and internal medicine, and one physical therapist) generated lists of difficulties independently. Then, these lists were screened for duplicates, merged and passed on to the six members of the “patient board” who were asked to add other missing difficulties. The final list, along with other evaluation forms, is handed to patients prior to each annual checkup.
Weight regain was computed as the relative change between weight at 12 months and at the latest annual checkup. Responses to the 26 weight maintenance difficulties were analyzed in terms of frequencies, median, mean, and SD. To explore whether the difficulties could be grouped into meaningful factors a principal component analysis (PCA) with varimax rotation was carried out (suitability of the data evaluated by using the Bartlett’s test and the Kaiser–Meyer–Olkin Measure of Sampling Adequacy, KMO). The Kaiser criterion (eigenvalues > 1) was used to determine the factors retained for rotation. Item allocation was based on factor loadings ≥0.40. Cross loaded items were assigned to the main factor if the difference between loadings was ≥0.20, otherwise they were dismissed. Factors were considered solid if at least four assigned items had loadings exceeding 0.50. Based on the resulting factorial structure, individual factor scores were computed for each subject as means of the assigned difficulties and used for further analyses. The internal consistencies of these factors were analyzed by using Cronbach’s alpha and differences were tested by using the Wilcoxon Signed Rank Test.
Associations between the derived factors and clinical data were evaluated by using Spearman’s rank correlation or the Mann–Whitney test. To identify the most important predictor of weight regain, stepwise regression analysis was fitted including the derived factors as predictors, as well as age, sex, education, and follow-up time as covariates. The minimum significance level for entry and for staying in the equation was 0.05 and p = 0.1 to exit. Statistical analyses were performed with SPSS. A p value < 0.05 was considered statistically significant.
Sample characteristics and clinical data
Weight maintenance difficulties were assessed in 88 out of 102 patients at a mean follow-up time of 1.48 years (range 1–3). Patients who were lost to follow-up were younger, weighed more at baseline, and lost less weight. The final sample included more women and was characterized by a baseline BMI of 49.5 kg/m2 and a 12-month weight loss of 24.3% (Table 1). The follow-up data revealed a mean BMI of 42 kg/m2 (±8.74), a weight loss of 14.9% (±13.3), and a regain of 12.4% (±12.2).
Weight maintenance difficulties
Most patients rated the 26 items without describing additional difficulties (Fig. 2). ‘Appetite’ received the highest overall agreement, i.e., the group mean of 2.97 as well as the amount of 87.5% of patients who agreed to some degree, were the highest respectively (Fig. 1). ‘Stress’ (M = 2.79; 71%) and ‘Pleasure eating’ (M = 2.78; 76%) were ranked second and third with respect to group mean. In contrast, ‘Lacked faith in long-term success’, ‘Financial constraints’, and ‘Boredom’ received the lowest average agreement (M = 2.05–2.08). ‘Health-related issues’, ‘Negative feelings’, and ‘Mental issues’ were characterized by a relatively high amount of fully agreeing patients on one side (i.e., >12%) and a rather average group mean on the other (Fig. 1).
The acquired data was suitable for a PCA (KMO = 0.860, Bartlett’s test: p < 0.001, all communalities ≥0.50, M = 0.66; SD = 0.08). Five factors with eigenvalues >1 were extracted and accounted for 66% of the variance. Four of the five factors were considered to be solid factors. The fifth factor was dismissed because only three items loaded >0.50 and two of these were cross loaded. The remaining four factors were composed of 21 items and interpreted as ‘Hedonic Hunger’, ‘Mental Distress’, ‘Binge Eating’, and ‘Demoralization’ (Fig. 2). The internal consistencies were good (three factors) or acceptable (one factor) (Fig. 2). Five items were not assigned to any factor because of cross loadings (Fig. 2).
Agreement was found to be highest with respect to ‘Hedonic Hunger’ and ‘Mental Distress’, with a very or extreme agreement (i.e., mean > 3) provided by 33% and 29% of patients, respectively (Table 2). In contrast, with respect to ‘Binge Eating’ and ‘Demoralization’ only 26% and 13% of patients provided such an agreement (Table 2). Of statistical significance were the following mean differences: ‘Hedonic Hunger’ > ‘Binge Eating’ (p < 0.01), ‘Hedonic Hunger’ > ‘Demoralization’ (p < 0.05), and ‘Mental Distress’ > ‘Binge Eating’ (p < 0.05).
A weak correlation with follow-up time was evident with respect to all factors except ‘Binge Eating’, i.e., the more time had passed since therapy completion, the more patients were troubled by these difficulties (Table 2). Two associations with socio-demographics were significant, i.e., women experienced more difficulties due to ‘Mental Distress’, and patients with high education experienced more difficulties due to ‘Binge Eating’ (Table 3). Correlations with age were not significant. A moderate inverse correlation was found between 12-month weight loss and ‘Demoralization’, i.e., the less weight had been lost during treatment the more demoralized patients were at follow-up (Table 3).
Weight regain was found to be correlated with all four factors, to the greatest extent with ‘Mental Distress’ (Table 3). The regression analysis revealed that weight regain could be explained by follow-up time (std. β = 0.400; p < 0.001), age (std. β = −0.217; p < 0.05), and ‘Binge Eating’ (std. β = 0.267; p < 0.01) (adjusted R2 = 0.297, F = 7.916, p < 0.01).
To our knowledge, this is the first study that quantitatively evaluated difficulties that obese patients might be experiencing while attempting weight loss maintenance during the first three, most critical years after treatment completion . In an almost complete sample of patients who had successfully completed an utterly intensified, 12-month lasting weight loss and lifestyle intervention, it was found that four factors, i.e., ‘Hedonic Hunger’, ‘Mental Distress’, ‘Binge Eating’, and ‘Demoralization’ explain the majority of difficulties. The closest association with the amount of weight regained was evident with respect to ‘Mental Distress’, however, when controlling for age and follow-up time, ‘Binge Eating’ was the most important predictor.
The patients evaluated in this study had reduced more than half of their excess weight within the first 6 months of treatment and successfully maintained it for the second 6 months while being treated under explicit consideration of factors known to be associated with weight maintenance [9, 18]. However, even in this selective group of intensively treated patients, weight began to regain at a rate of about 7.5% per year after therapy completion. Thus the present sample might provide an insight into those barriers that persisted even after receiving an exhaustive multiprofessional support at the weight loss stage.
Our results suggest that the patients of this group experienced four main barriers to weight maintenance during this time. The first one, ‘Hedonic Hunger’, reflects difficulties arising from the extent of pleasure a person associates with food intake and was named after a model of overeating that refers to critical aspects such as availability of highly palatable foods, encouraging social, and personal norms, and an individual’s susceptibility to food-related pleasure . An association with an external eating style also seems likely . Prior research has shown that hedonic hunger is elevated in obese patients regardless of age and sex, but can be reduced through surgically and nonsurgically induced weight loss [23, 24]. In the present study, almost nine out of ten patients experienced some degree of ‘hedonic hunger’ and the data suggest it to be a common issue for patients of different age, sex, and education that becomes even more prevalent with time.
The second barrier the patients were found to experience during weight maintenance was referred to as ‘mental distress’ because it reflects three important psychological aspects of weight regulation, i.e., stress [25, 26], emotional eating , and mental disorders . Interestingly, our study suggests that from patient perspective these issues are viewed as one difficulty. The reason for this might be that patients do not differentiate them. However, there is also evidence that support a close association between emotional eating, stress, and depression . From our clinical experience, there are indeed two interwoven aspects that become apparent upon further exploration: Firstly, ‘mental distress’ is described as exhausting and distracting, taking away the time and energy that would still be required to continue the appropriate lifestyle. Secondly, ‘mental distress’ is described as an emotional overload that exceeds newly acquired coping abilities and becomes the reason for falling back into relapse with respect to emotional eating. Difficulties arising from mental distress were as prevalent as those arising from ‘hedonic hunger’, but, in line with previous findings , they were more frequently experienced by women and by patients with younger age.
The third barrier comprised difficulties due to binge and loss of control eating and was referred to as ‘Binge Eating’. It is important to note that patients who met criteria for binge eating disorder had been transferred to psychotherapy prior to the program and therefore this barrier may reflect severity of subclinical symptoms rather than severity of the eating disorder. Binge eating behavior is a well-known issue associated with weight regain after nonsurgical as well as surgical weight loss therapy . The present results suggest that difficulties arising from ‘Binge Eating’ are to some extent different from the other difficulties. More specifically, this barrier seems to be of less overall prevalence and to be taking a different course which is characterized by an early manifestation without further progression over time. The present results also suggest that ‘Binge Eating’ as a barrier to weight maintenance might not be a matter of age or sex, but of education. Patients with higher education seemed to be more troubled by it, which is surprising as education has either not been associated with binge eating behavior in the past  or in the opposite direction, i.e., lower education predicted reoccurrence of binge episodes . The reason for this mismatch deserves further investigation.
The fourth barrier, ‘Demoralization’, comprises a set of seemingly unrelated difficulties. However, in the absence of objective standards, social support, finances, health, motivation, and faith could become subject to perspective and interpretation. Agreement to these difficulties may therefore reflect an implicit demoralized state instead of an explicit obstacle. In fact, demoralization has been introduced as a basic factor of psychopathology and personality . In line with this, we found that the degree of ‘Demoralization’ was closer related to initial weight loss than to weight regain. Moreover, many of the beliefs, conceptions, and thinking styles that have been linked to weight maintenance could be related to demoralization, including self-efficacy, an external locus of control, a dichotomous thinking style, dissatisfaction with weight loss, body image, a cost versus benefit imbalance, or the conception of social support [9, 32]. In the present sample, the experience of ‘Demoralization’ was comparable between men, women, and patients of different age. However, the results suggest that it might be more frequently experienced by patients with lower education.
The experience of each barrier was related to weight regain. This underlines the validity of patient perspective and suggests that the difficulties patients struggle with may indeed refer to reasons why they fail and what kind of support they need. Our data also suggest that patient perspective alone cannot explain all differences in weight regain and therefore other factors such as metabolic and endocrine responses to weight loss have to be considered as well [19, 33, 34]. Nevertheless, evaluating patient perspective quantitatively might be useful for identifying major barriers which could then serve as a framework for providing more individualized and targeted behavioral interventions [2, 12] as part of a multidisciplinary approach to long-term maintenance . For example, for the patients evaluated in the present study stimulus control techniques or training in mindfulness eating  might have been effective for managing ‘Hedonic Hunger’, stress reduction trainings could have had the potential to reduce stress and emotional eating , interventions for binge eating disorders could have been helpful for managing the less severe manifestations of this eating disorder , and strategies for increasing self-efficacy and motivation might have been supportive for the demoralized patients [19, 32, 38].
In line with previous findings [14, 39, 40], the present results suggest that ‘Binge Eating’ and ‘Mental Distress’ were the most important barriers with respect to actual weight maintenance. Moreover, for the first time we found that time might have mediated their importance suggesting a complementary significance. According to this, ‘Binge Eating’ was more relevant for the weight regained within the first few months after therapy completion, whereas ‘Mental Distress’ was for the weight regained over the whole follow-up period. How the relevance of certain difficulties might change over time should be further evaluated as it could have important implications on the support that is required at different stages.
The following limitations have to be considered. Firstly, the list of potential difficulties was developed based on multiprofessional expertize and selective patient feedback, without a theoretical underpinning. It should not be considered exhaustive as rare difficulties such as conflict with identity after weight loss and negative beliefs about weight management  were not assessed. Secondly, mental disorders were not differentiated as separate difficulties and thus the respective item was subject to interpretation by each patient. Thirdly, the representativeness of the present sample is limited due to the high percentage of women, the ethnical homogeneity and due to the treatment modality which required patients to invest tremendous amounts of time and energy . It is also important to note that only a ratio of 3.4:1 was achieved between 88 patients and 26 assessed difficulties. This is in accordance with current practice of applying PCA but far below the recommended ideal of >20:1 and does not allow to draw substantive conclusions to other samples or populations . Therefore, the present results need to be interpreted as being valid only in this selective group of patients who had received exhaustive multiprofessional support. Fourthly, it remains unclear if there is a causal relation between difficulties and weight regain. The difficulties could merely reflect retrospective explanations with little predictive value for future weight regain. A longitudinal observation should evaluate this further. Lastly, the patients in this study were treated nonsurgically and results may be different in otherwise treated groups. Bariatric surgery for example has been linked to exaggerated secretion of appetite-regulating gut hormones as well as to changes in appetite, taste and food preference [43, 44] which could alter the pattern and magnitude of the experienced difficulties.
In conclusion, a quantitative assessment of the various difficulties reduced obese patients experience during the first years after nonsurgical weight loss can help identify valid barriers to weight loss maintenance. The current list of difficulties and analysis is an important first step to fully develop and evaluate, in a larger sample, patients self-reported difficulties in maintaining weight loss after clinically significant weight reduction.
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Fischer, M., Oberänder, N. & Weimann, A. Four main barriers to weight loss maintenance? A quantitative analysis of difficulties experienced by obese patients after successful weight reduction. Eur J Clin Nutr 74, 1192–1200 (2020). https://doi.org/10.1038/s41430-020-0559-x