ABSTRACT
Background and Aim:
The prevalence of obesity is increasing and people with obesity (PwO) continue to struggle with their weight. We aimed to describe the experiences of people who struggled with their weight at an early age (EAO) or at a later age (LAO), their discussions with their healthcare practitioners (HCPs) and episodes of depression and anxiety.
Methods:
We gathered information from 1,000 adults PwO, categorized them into EAO and LAO and analyzed their responses regarding weight loss attempts, discussions with their HCP, perceptions about obesity and episodes of depression/anxiety.
Results:
Mean age was 36.6 years old, and 73.0% were AAO. EAO had significantly fewer weight loss attempts and had fewer interactions with their HCP. EAO reported less HCP support for weight management, were less motivated to lose weight, and experienced more episodes of anxiety/depression. Significant association between greater obesity class with longer duration of weight problems, and depression and anxiety. EAO PwOs were less likely to discuss weight problems with their HCP.
Conclusion:
It is fundamental that HCPs recognize and address weight issues in PwO who are at risk of obesity in adulthood as early as adolescence. They should also take the lead in addressing these psychophysiological concerns by involving the parents in the decision-making process and facilitating shared planning. These may enhance their motivation to lose weight, boost self-confidence, and reduce the complications of obesity.
Keywords: ACTION-IO study, age of onset, depression, obesity, primary healthcare practitioners, weight problems
Introduction
The 2016 World Health Organization’s (WHO) statistics showed that around 650 million adults aged 18 years and older have obesity.[1] The prevalence of overweight and obesity in Saudi Arabia is approximately 30% and is increasing.[2]
Early age of onset of obesity (EAO) or obesity during adolescence was found to significantly increase the risk of obesity in adulthood and obesity-related complications.[3] Studies have shown that childhood obesity predicted a higher BMI in adulthood and had a greater likelihood of having persistent adulthood obesity.[4,5,6]
People who had EAO were more dissatisfied with their body appearance and had lower self-esteem.[7] EAO were more predisposed to emotional distress and psychiatric problems compared to those with late age of onset of obesity (LAO).[8,9] This creates a cycle of desire to lose weight and eventually gain weight pushing for higher tendencies for emotional distress and lowered self-esteem.[10,11] Despite the mounting evidence that links weight stigma to the psychophysiological impacts on people with obesity (PwO), little is known about the intricate relationship between PwO’s experiences in the actual world and their struggles with weight.[5,6,7,8,9,10] Moreover, there is a dearth of research on weight struggles and the experiences of PwO in managing their weight in their early or later years of their life.[5,6,7,8,9,10]
Here we characterized and described the real-time experiences and struggles of PwOs with their weight, their weight loss attempts, their discussions with HCP, and the prevalence of diagnosed anxiety and depression using the data from the ACTION-IO study.
Materials and Methods
Study design
This study is part of the Awareness, Care and Treatment In Obesity MaNagement-International Observation (ACTION-IO) collaborative study, which is a cross-sectional, non-interventional, descriptive study which surveyed over 14,500 PwOs across 11 countries between June 2018 and October 2018. The study was approved by the Institutional Review Board of King Fahad Medical City, Riyadh, Saudi Arabia (H-01-R-012) dated 9 July 2018.
Study participants and recruitment
We recruited all patients who were ≥18 years of age, male or female, living in Saudi Arabia, and who had a current body mass index (BMI) of ≥30 kg/m2. Participants were excluded if they were on intense fitness or bodybuilding programs and, if female, were pregnant at the time of the study.
Procedures
We interviewed participants online using a survey questionnaire that was developed by an international steering committee of obesity experts, including three medical doctors employed by Novo Nordisk, the study sponsor, and a representative from Saudi Arabia, as described in the primary manuscript by Caterson et al.[12] All participants provided informed consent before completing the screening questions and survey. Each qualified participant who completed the survey was offered a nominal honorarium for completing the survey.
In this survey, we asked the question “How old were you when you first remember having problem/s with excess weight or obesity” defined as experiencing difficulty in achieving weight loss and maintaining their desired weight. From their responses, we then grouped the respondents into EAO (early age of onset when they started to experience problems with their weight at age ≤20 years old) and LAO (late age of onset when they started to experience problems with their weight at age >20 years old). We based this age cut-off on two previous studies that suggested the age of onset of severe obesity and development of problems related to severe obesity at approximately 20 years old.[4]
Research tool and measures
The survey questionnaire used for this study was developed by an international steering committee of obesity experts, including three medical doctors employed by Novo Nordisk, the study sponsor, and a representative from Saudi Arabia, as described in the primary manuscript by Caterson et al.[12] The Saudi ACTION-IO questionnaire included questions on the demographic characteristics of the participants, obesity awareness and perceptions, and attitudes toward obesity and management. We also asked questions on their conversations about weight problems with their HCP and the reasons why they might not talk with their HCP. A question was asked whether they were diagnosed with depression and or anxiety.
Statistical analysis
Statistical analysis was conducted using the Statistical Program for Social Sciences (SPSS) version 23.0 (SPSS Inc., Armonk, New York, USA). Frequency distribution was reported as numbers and percentages for categorical data. Continuous data were expressed as mean and standard deviation with their corresponding range of values. A Chi-square test was done to test the significant differences in the proportion between the two groups (EAO versus LAO). The association between categorical variables was done using the Chi-square statistics. Independent samples t-test was used to determine significant difference in the means between the two groups. A P value of < 0.05 was considered statistically significant.
Results
Demographic profile
A total of 2,669 PwOs were invited and 1,000 completed the survey and comprised our study population. The mean age was 36.6 ± 13.1 years old. Majority were males, and 64.6% were with class I obesity (BMI 30.0 to 34.9 kg/m2). Majority of PwO (73.0%) had LAO of weight struggle. Detailed information is shown in Table 1.
Table 1.
Characteristic profile of 1,000 surveyed people with obesity (PwO) in Saudi Arabia
| Demographic variables | All PwO n=1000 | EAO n=304 | LAO n=696 | P |
|---|---|---|---|---|
| Age in years, mean, and SD (min – max) | 36.6±13.1 (18-74) | 26.6±7.7 (18-65) | 43.84±11.9 (23-74) | <0.001 |
| BMI in kg/m2, mean, and SD (min – max) | 34.0±2.3 (30-41) | 34.3±2.4 (29.9-40.2) | 33.9±2.3 (30.0-40.5) | 0.039 |
| Gender, n (%) | ||||
| Males | 565 (56.5%) | 198 (65.1%) | 367 (52.7%) | 0.030 |
| Females | 435 (43.5%) | 106 (34.9%) | 329 (47.3%) | |
| BMI class, n (%) | ||||
| Class I (BMI of 30-34.9) | 646 (64.6%) | 202 (66.5%) | 444 (63.8%) | 0.074 |
| Class II (BMI of 35-39.9) | 313 (31.3%) | 97 (30.9%) | 216 (31.0%) | |
| Class III (BMI of ≥40) | 41 (4.1%) | 5 (1.6%) | 36 (5.2%) | |
| Level of education, n (%) | ||||
| Less than secondary | 433 (43.3%) | 166 (54.6%) | 267 (38.4%) | <0.001 |
| Diploma, Bachelors | 309 (30.9%) | 109 (35.9%) | 200 (28.7%) | |
| Advanced (postgraduate degree) | 258 (25.8%) | 29 (9.5%) | 229 (32.9%) | |
| Marital status, n (%) | ||||
| Married | 711 (71.1%) | 95 (31.3%) | 616 (88.5%) | <0.001 |
| Single | 257 (25.7%) | 207 (68.1%) | 50 (7.2%) | |
| Divorced or separated | 17 (1.7%) | 1 (0.3%) | 16 (2.3%) | |
| Widowed | 15 (1.5%) | 1 (0.3%) | 14 (2.0%) |
PwO—people with obesity; EAO—early age onset of problem with weight (≤20 years old); LAO—later age of onset of problem with weight (>20 years old); SD—standard deviation; BMI—body mass index
History of weight loss
Majority (81.2%) of PwO believed that they have lost weight but regained weight over time. The LAO group had more significant weight loss attempts than EAO (3.9 ± 3.6 versus 2.6 ± 2.3, P < 0.001). However, a greater proportion of the EAO group perceived that they were just overweight and not obese compared to the LAO group (P = 0.004). The mean BMI of respondents who perceived they were overweight was 33.5 ± 2.3 kg/m2, whereas for those who perceived themselves as having obesity was 34.3 ± 2.3 kg/m2 and 34.5 ± 2.2 kg/m2 for those who perceived themselves as extremely obese.
Frequency of visits and discussions about weight with their HCP
Only 552 of PwO had engaged in a discussion with their HCP in the past six months, 192 (34.8%) were EAO and 360 (65.2%) were LAO. The mean number of interactions with their HCP was 3.65 ± 2.8 times, significantly fewer visits among EAO compared to LAO (3.10 ± 2.1 times versus 4.0 ± 3.0, P < 0.001).
PwO discussion with their HCP and their feelings after the discussion
EAO reported significantly less motivation and less support and were less relieved after discussion with their HCP regarding their weight problems compared to LAO (P = 0.048, P = 0.001 and P = 0.011, respectively). Overall, there was a low percentage of PwO who reported positive feelings compared to the percentage who experienced negative feelings after discussion with their HCP. [Figure 1] PwO with class III obesity category were less likely to discuss their weight problems with their HCP and were more likely to have a negative perception of the discussing weight problems with their HCP (P = 0.030).
Figure 1.
Responses of 552 PwO to questions regarding their feelings after their recent discussion with their primary healthcare practitioner (early age onset of problem with weight versus adult age of onset of problem with weight)
Perceptions about obesity and weight management and reasons why PwO might not discuss weight management with their HCP
Fewer EAO perceived obesity as a chronic disease. In contrast, more LAO believed that obesity treatment is a team effort between them and their HCP, believed that the hospital was a good resource for those looking to lose weight and believed that maintaining a healthy weight is a priority for the country’s healthcare system [Figure 2].
Figure 2.
Perceptions of PwO regarding obesity and weight management (early age onset of problem with weight versus adult age of onset of problem with weight)
Reasons why PwO might not want to discuss weight management with their HCP
The two most common reasons why PwO might not discuss weight loss management plans with their HCP were loss of motivation to lose weight and their belief that they are not able or was hard for them to lose weight. A higher proportion of EAO were not motivated to lose weight, while more LAO reported that they are not able or hard for them to lose weight. A complete description of these reasons comparing EAO and LAO is shown in Figure 3.
Figure 3.
People with obesity (PwO) perceived reasons why they might not discuss weight management/weight loss plans with their primary HCP (early age onset of problem with weight versus adult age of onset of problem with weight)
Episodes of depression and/or anxiety
One hundred and two (10.2%) of PwO claimed to have been diagnosed with anxiety and/or depression during their lifetime, more among EAO than LAO (18.8% versus 7.1%, P < 0.001). Depression and/or anxiety was significantly positively associated with a greater obesity class (class III obesity).
Discussion
For decades, weight loss and weight intervention programs to address obesity have been a widely discussed issue. Several protocols and weight loss/lifestyle programs have sprung up, and many fitness and diet/nutrition centers have been established.
Weight loss success
This study showed that only 22.6% of the respondents were successful in losing weight, which is relatively lower than the previously reported prevalence of successful weight loss in South Korea and Italy (38%).[13,14] There are a variety of reasons why people are unable to lose weight or gain weight after a weight loss intervention program. Apart from the compensatory changes from the hypothalamic-gastrointestinal tract and many other tissues that influence appetite, motivation to lose weight is essential to a successful weight loss intervention program.[15] A large proportion of our PwO is believed to have lost weight but regained eventually over time probably because of unsustained motivation and commitment to lose weight.[16,17,18]
Obesity-focused weight discussion between PwO and their HCP
This study highlights important topics that HCP should discuss with their patients regarding obesity. Conversations and discussions about weight and weight loss management between PwO and their HCP are critical components of an effective weight loss intervention program. PwO may find it challenging to start conversations with their HCP, especially among EAO. PCP as front liners plays a crucial role in addressing and starting a constructive dialogue about weight management that is customized, mutually agreed-upon approach that prioritizes the patient’s psychological well-being.[19,20] EAOs in particular have a higher tendency to have misperception of their body weight and may have distorted body image which HCPs can address during discussions with their patients.[21,22,23] Mutual agreements on a tailored approach should be discussed to avoid misunderstanding and misalignment to the goals of weight reduction.[24,25,26] The discussion ideally be more comfortable, more motivating and not stigmatizing, thus speaking to their patients with mutual respect and collaboration to increase patients’ compliance to the weight loss intervention program and attendance to follow-up visits.[25,26]
Gaps to communication between PwO and HCP
In this study, merely 45% of PwO had discussed weight with their HCP, much less among EAO, and many PwO had a negative perception after talking with their HCP, which are clear evidence that a communication gap exists between PwO and HCP. PwOs frequently make their initial contact with the healthcare system through PCPs. As frontliners, PCPs as well as HCPs should build and enhance patients’ trust in the healthcare system with regard to weight reduction and weight intervention programs. The ability of HCP to communicate effectively to deliver the message of “feeling” PwO sentiments may help bridge the communication gap and provide an effective and improved obesity management program.[27]
Enhancing PwO motivation to lose weight and breaking barriers to discuss weight loss intervention with an HCP
One of the most important components of a successful and long-lasting weight loss program is motivation to lose weight, and we have shown that in this study.[28] Strong unfavorable attitudes and preconceived notions about PwO held by many HCPs coupled with PwOs skepticism that leads to mistrust, poor adherence, no motivation and lower-quality care should be addressed and not practiced.[29,30] Any disagreements between HCP and their PwO patients on how they should be treated could eventually result in an unhealthy relationship between both parties.[29] HCPs have the duty to reduce stigma and enhance health outcomes through patient-centered, productive communication, treating PwO as individuals, recognizing prejudice and presumptions, creating a welcoming environment, and pursuing lifelong learning about the negative effects of obesity.[27,28,29] Special attention to teens and adolescents who have obesity because they typically do not seek help from a health professional, unless peer or social pressure comes in, or become concerned about appearance, and sometimes depend on how they are feeling about themselves.[30,31] To effectively address barriers to weight loss, programs for addressing childhood and adolescent obesity should begin as soon as diagnosed. Programs should focus on weight loss motivations, build on positive feelings to boost confidence and trust in the process, assist in helping the patients understand that obesity is a chronic disease that can result in several complications, support weight maintenance and sustained positive behaviors, and involve the parents as co-managers.
Anxiety and depression
Many people blame themselves when they fail at weight loss, give up on the goal, and eventually experience anxiety and depression.[32] The pressure to be thinner or have an attractive body type, especially among EAOs, can have a substantial negative impact on one’s sense of worth, self-esteem, and general mental health, and may contribute to depression.[33] Our results, demonstrating a substantial correlation between depression and a higher obesity class and a higher frequency among EAO, are consistent with previous studies.[34,35,36] Comparably, a different study revealed a much greater prevalence of depression (24%) among people under the age of twenty-one than our results.[37] A study showed that teenagers had a 5.68 percent higher chance of being obese and have a higher frequency of depressive symptoms, experiencing low self-esteem, discrimination from peers, and other clinical and psychosocial issues that require the attention of psychological healthcare providers.[36]
Strengths and limitations of the study
PCPs will benefit from this study in terms of how they should handle, manage, and communicate with PwOs particularly those who are adolescents with obesity. PwOs frequently make their initial contact with the healthcare system through PCPs. Despite only a little more than 10% of our respondents who believed that their HCP is not interested in helping them remains a concern for healthcare practitioners (HCPs) to reach the ultimate goal of reducing the incidence of obesity. This study has limitations similar to those found in the global ACTION-IO study, including its cross-sectional and descriptive nature, and respondent recall bias including the diagnosis of depression and/or anxiety by an HCP. On the other hand, we believe on this study’s several strengths in discussing why and how PwO struggle with weight (early or late), their perceptions and attitudes towards their HCP and towards weight loss intervention strategies, and the prevalence of anxiety and depression among PwO. We acknowledge that other factors such as age, sex, income, and region (for example) may also contribute to these associations and as such these results present a limited view of the complete dynamics between BMI and mental health. Furthermore, this paper suggests several strategies to reduce the prevalence of obesity in Saudi Arabia. Weight loss intervention programs when instituted and identified as early as adolescence may result in a successful weight loss program for PwO. Enhanced primary HCP-patient relationship to build trust, co-managed weight loss intervention programs and psychological support while PwO go through phases of weight loss may improve outcomes of weight loss interventions.
Conclusion
Management of obesity should start as early as adolescence when diagnosed, the earlier the better. PwOs regardless of their age need more motivation and interaction with their primary HCP to obvert their feeling of not being supported regarding their weight problems and the negative feelings about their HCP. Decreasing the communication gap between PwO and their HCP will improve the success rate of weight loss intervention, increase awareness and knowledge of obesity, and decrease the incidence of obesity-related anxiety and/or depression. Primary HCPs should take the initiative for an enhanced HCP-PwO interaction through shared planning and decision-making process for weight loss management as early as adolescence or when they were diagnosed with obesity. Training programs particularly for PCPs should include communication and addressing obesity as well as weight management program.
Financial support and sponsorship
Research relating to this manuscript was funded by Novo Nordisk.
Conflicts of interest
AA Alfadda 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. M Shams and M Yahia are employees of Novo Nordisk. RA Almubark, S Alqahtani, AC Isnani, and Ali Alqarni have no conflicts of interest in this work.
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