ORIGINAL ARTICLE
Weight loss behavior in obese patients before
seeking professional treatment in Taiwan
Tsan-Hon Liou
a,b, Nicole Huang
c, Chih-Hsing Wu
d, Yiing-Jenq Chou
c,
Yiing-Mei Liou
e, Pesus Chou
c,∗aDepartment of Physical Medicine and Rehabilitation, Taipei Medical University-Wan Fang Hospital,
Taipei, Taiwan
bGraduate Institute of Injury Prevention and Control, College of Public Health and Nutrition,
Taipei Medical University, Taiwan
cCommunity Medicine Research Center and Institute of Public Health,
National Yang-Ming University, Taipei, Taiwan
dDepartment of Family Medicine, National Cheng Kung University Hospital, Tainan, Taiwan
eInstitute of Community Health Nursing, National Yang-Ming University, Taipei, Taiwan
Received 13 March 2008 ; received in revised form 22 September 2008; accepted 14 October 2008
KEYWORDS
Obesity;
Anti-obesity drug; Weight expectation; Weight loss behavior
Summary
Objective: To assess weight loss strategies and behaviors in obese patients prior to
seeking professional obesity treatment in Taiwan.
Design: A cross-sectional study was conducted between 1 July 2004 and 30 June
2005.
Setting and subjects: Obese subjects (1060; 791 females; age,≥18 years; median
BMI, 29.5 kg/m2) seeking treatment in 18 Taiwan clinics specializing in obesity
treat-ment were enrolled and completed a self-administered questionnaire.
Results: Of the 1060 subjects, the prevalence of anti-obesity drug use was 50.8%;
more females than males used anti-obesity drugs (53.6% vs. 42.4%). Approximately one-third of normal weight or overweight subjects with no concomitant obesity-related risk factors took anti-obesity drugs. Merely 26.7% of female and 34.7% of male subjects regularly received panel-recommended levels of physical activity. Further, two-thirds (66.1%) of subjects expressed an intention to lose more than 20% of initial body weight. Multiple logistic regression analyses revealed a substan-tially higher odds ratio (OR) for anti-obesity drug use in females than in males (OR, 2.3, 95% CI: 1.7—3.2). Obesity was also associated with younger age and higher body mass index (BMI). Females were more likely than males to have unrealistic
∗Corresponding author at: Community Medicine Research Center and Institute of Public Health, National Yang-Ming University,
155 Li-Nong St., Sec. 2, Peitou, Taipei, Taiwan. Tel.: +886 2 28267050; fax: +886 2 28201461.
E-mail address:[email protected](P. Chou).
1871-403X/$ — see front matter © 2008 Published by Elsevier Ltd on behalf of Asian Oceanian Association for the Study of Obesity.
weight loss goals. Younger patients and those with high BMI were also more likely to have unrealistic weight goals than their reference groups.
Conclusion: Obese patients in Taiwan tend to use anti-obesity drugs, receive
inade-quate physical activity and have unrealistic weight loss expectations before seeking professional treatment for obesity.
© 2008 Published by Elsevier Ltd on behalf of Asian Oceanian Association for the Study of Obesity.
Introduction
According to obesity treatment guidelines, three major components of weight loss therapy are dietary therapy, increased physical activity and behavior therapy[1—4]. Lifestyle therapy should be attempted for at least 6 months before considering pharmacotherapy. Additionally, pharmacotherapy should be considered as an adjunct to lifestyle therapy in obese or overweight patients with con-comitant obesity-related diseases. Studies have shown that most patients who have been pre-scribed anti-obesity drugs, including orlistat and sibutramine, are not treated in accordance with obesity treatment guidelines [5,6]. Many patients continue to take anti-obesity drugs even after achieving normal body weight.
Further, although individuals attempting to lose weight are more likely to engage in regular phys-ical activity, most have not permanently adopted a physically active lifestyle [7]. Jakicic and Otto demonstrated that more than 80% of individu-als engaging in physical activity as a weight loss strategy expend insufficient energy to significantly improve health, let alone weight loss [8]. Cur-rent international association for study of obesity (IASO) guidelines recommend 60 min of moderately intense physical activity on most days to prevent weight gain and 60—90 min on most days to avoid regaining weight following significant weight loss [9]. Therefore, those at risk for weight gain or seek-ing to maintain recent weight loss must maintain the recommended activity levels. Obese subjects are initially encouraged to reach a target level of 30 min per day of moderately intense physical activ-ity according to current guidelines for the general population[10]. Further increase in duration, fre-quency, or intensity may be needed to meet the current guidelines[9].
In a study of binge eating disorders (BED), ideal, satisfactory and minimum acceptable BMI were considered by subjects to require average weight reductions of 36, 29 and 23%, respectively [11]. Even the ‘‘disappointed’’ body mass index (BMI) was an average 14% reduction in current weight and
1.5—3 times higher than expert recommendations (5—10%). Obese patients tend to have unrealis-tic weight loss expectations. A significant disparity has been noted between what physicians and what patients consider ideal weight loss[12]. Studies of goal setting have observed that weight loss goals which are unrealized or overly difficult to achieve tend to increase the likelihood of negative emo-tions, impaired task performance and abandonment of weight loss goals. Dalle Grave et al. suggested that baseline weight loss expectations are inde-pendent cognitive predictors of attrition in obese patients entering a weight loss program[12]. Unre-alistic weight loss goals should be tackled at the very beginning of treatment.
As more and more subjects aware the impor-tance to lose weight, there are lots of weight losing and slimming methods in Taiwan. It is important to know how people attempt to lose weight. Given the limited available data in Taiwan, this study exam-ined weight loss behavior, including anti-obesity drug use, weight loss expectation and daily level of physical activity in Taiwanese adults prior to seek-ing professional obesity treatment. This study will provide valuable data for clinical physicians better understanding of their patients.
Methods
Sampling of obesity clinics and subjects were shown in Fig. 1and described in detail elsewhere [13]. This study was approved by the Committee of Institutional Human Subject Review Board of Taipei Medical University-Wan Fang Hospital, Tai-wan. Each subject completed a self-administered questionnaire with help from a trained assistant. The questionnaire was divided into three sections: (1) a socio-demographic section for recording data for age, gender, marital status, education level, tobacco and alcohol use, monthly income, etc.; (2) a medical history section for hypertension, dyslipi-demia, CHD, type 2 diabetes and sleep apnea data; (3) a weight loss section to examine behavior during the previous year, such as weekly level of physical
Figure 1 Sampling method and flow of subjects
(TMASO*: Taiwan Medical Association for Study of Obesity).
activity, diet control and use of anti-obesity drugs. BMI was calculated as weight in kilograms divided by height in meters squared (kg/m2). The following BMI categories were utilized: <24, normal weight; 24—26, overweight; ≥27, obese [14]. We use the Short-Form Self-administered International Physical Activity Questionnaire (IPAQ) assess their amount of past 7-day physical activity, a culture adoptive tool that could prove useful for both clin-icians and researchers in the field and suitable for international comparison[15—17]. This 7-day recall questionnaire consists of seven questions assessing the frequency and duration of participation in vigorous, moderate-intensity, and walking activity as well as the time spent sitting during a weekday, globally in all contexts (leisure-time, transporta-tion, occupatransporta-tion, and house-work) of everyday life. Scores for vigorous, moderate, and walking activity are calculated in minutes per week, and is time spent sitting per day. The sum of the above three activity scores gives an indicator of vigorous, moderate and walking physical activity (VMWPA). Recommendations for data truncation made by the IPAQ executive committee as of April 2004 were applied. Taiwanese version was validated in
2004 and demonstrated reasonable test—retest reliability (ICC = 0.67) and fairly good inter-method validity (Spearman’s rho = 0.86)[18,19].
Diet and weight history, weight loss expecta-tions and primary motivation for seeking treatment were systematically recorded. Weight loss goals were assessed by asking, ‘‘How much weight do you intend to lose and in what duration?’’
Statistics
Statistical analyses were performed using SPSS for Windows version 13.0 (SPSS, Inc., Chicago, IL, USA). Prevalence data were presented as percent-ages (%). Chi-squared test and linear trend test were conducted. Multiple logistic regression analy-ses were performed to asanaly-sess associations between behaviors violating obesity treatment guidelines and demographic variables, including gender, age and current BMI. A p-value less than 0.05 was con-sidered statistically significant.
Results
Basic characteristics of respondents
Table 1 shows the basic demographic data for all respondents. Of the 1060 respondents, 53.7% (569/1060) were college educated, and 51.5% (546/1060) were married. Approximately one-third of the patients were 25—35 years old. Most resi-dents had a monthly income of NT$ 10,000—50,000.
Appropriateness of use of anti-obesity drug
Of the 1060 respondents, 16% (179/1060) had nor-mal weight, 15.6% (165/1060) were overweight with no co-morbidity, 6.7% (71/1060) were over-weight with at least one co-morbidity and 60.2% (638/1060) were obese. Of the 1060 respondents, 536 (51%) had used at least one anti-obesity drug, including orlistat, sibutramine or other unproven weight loss drugs. According to obesity treatment guidelines in Taiwan, pharmacotherapy should be considered as an adjunct to lifestyle therapy in patients with a BMI≥ 27 without concomi-tant obesity-related diseases and patients with a BMI≥ 24 with concomitant diseases. However, approximately one-third of the subjects in this study had taken anti-obesity drugs without pre-scription. Further, use of anti-obesity drugs was significantly more common in females than in males. A linear trend was observed between anti-obesity drug use and BMI, indicating that use of
Table 1 Demographic characteristics of participants (n = 1060).
All (%) Female (%) Male (%) p-Value for2-test
Age (years) 0.087 18—24 196 (18.5) 134 (16.9) 62 (23.0) 25—34 331 (31.2) 244 (30.8) 87 (32.3) 35—44 268 (25.3) 209 (26.4) 59 (21.9) 45 265 (25.0) 204 (25.8) 61 (22.7) Marital status 0.001 Unmarried 464 (43.8) 326 (41.2) 138 (51.3) Married 546 (51.5) 419 (53.0) 127 (47.2) Others 50 (4.7) 46 (5.8) 4 (1.5) Educational level <0.001
≤Senior high school 148 (14.0) 129 (16.3) 19 (7.1)
Senior high school 343 (32.6) 268 (33.9) 75 (27.9)
≥College/University 569 (53.7) 394 (49.8) 175 (65.1) Monthly income (NT$) <0.001 ≤10,000 260 (25.8) 205 (27.7) 55 (20.6) 10,001—30,000 358 (35.6) 285 (38.5) 73 (27.3) 30,001—50,000 253 (25.1) 174 (23.5) 79 (29.6) ≥50,001 136 (13.5) 76 (10.3) 60 (22.5)
anti-obesity drugs increased as BMI increased in all subjects (Table 2).
Physical activity level
Physical activity is essential for weight manage-ment. Nearly 62% of subjects did not regularly engage in moderate or vigorous physical activity. In this study, only one-quarter (26.0%) of subjects reg-ularly engaged in the minimum suggested level of physical activity[20]. According to IASO guidelines, 60—90 min of moderate intensity activity or lesser amounts of vigorous intensity activity on most days of the week is required to prevent weight gain. Three hundred minutes of physical activity (includ-ing walk(includ-ing) per week is the minimum requirement to prevent unhealthy weight gain[9]. In this study, only 28.7% of all subjects (27% of females and 34.7% of males), received the recommended 300 min of physical activity per week. Men were significantly less inactive and had a higher proportion of physi-cally active than did women (Table 3).
Anticipated weight loss
In accordance with published weight loss guide-lines, patients were expected to lose 10% of initial body weight after a 6-month weight loss program [20]. The target rate of weight reduction was set at approximately 1—2 lb/week (2—4 kg/month). How-ever, most respondents had unrealistic weight loss goals. Two-thirds of subjects expressed a desire to lose more than 20% of initial body weight, and
females tended to have more dramatic weight loss goals than males (p < 0.001). Moreover, 45% of females wanted to lose as much as 30% of their ini-tial body weight. In this study, the anticipated rate of weight reduction was much higher than what is reasonable as the guideline suggested. Approx-imately half of the subjects set a weight loss goal of 2—5 kg/month whereas 22% of subjects wanted to lose weight at a rate of 6 kg/month or higher. Females also expected to lose weight faster than males (Table 4).
Risk factors for unhealthy weight loss
behavior
Multiple logistic regression analysis was performed to assess the relationship between basic demo-graphic characteristics and unhealthy weight loss behaviors. The analytical results showed that females were more likely than males to take anti-obesity drugs (OR: 2.3; 95% CI: 1.7—3.2), have inadequate physical activity (OR: 1.7; 95% CI: 1.2—2.3), and have unrealistic weight loss goals (OR: 5.8; 95% CI: 3.8—8.8). A linear trend was observed in subjects with higher BMI, who were more likely to take anti-obesity drugs and have unrealistic weight loss goals than those with normal BMI. Anti-obesity drugs use, inadequate physical activity and unrealistic weight loss goals were more common in younger subjects than in those above age 45. Further modeling by multiple logistic regression analysis revealed a similar result; how-ever, low levels of physical activity but not higher
T able 2 P revalence of anti-obesity drug use presented by body mass index (BMI) and co-morbidity (n = 1060). All Female Male No. of subjects No. of drug user P revalence (%) p * No. of subjects No. of drug user P revalence (%) p * No. of subjects No. of drug user P revalence (%) p * BMI (kg/m 2) <0.01 <0.01 <0.01 <24 172 70 40.7 160 67 41.9 12 3 2 5 24—26( − ) 163 73 44.8 146 66 45.2 17 7 41.2 24—26(+) 68 32 47.1 51 30 58.0 17 2 11.8 27—29 226 118 52.2 174 99 56.9 52 19 36.5 30—34 256 130 50.8 158 91 57.6 98 39 39.8 ≥ 35 175 116 65.7 102 71 69.6 73 44 60.3 (− ) with no co-morbidity and (+) with co-morbidity . *p -V alue for linear trend.
weight loss goals were predictive of anti-obesity drug use in this age group (Table 5).
Discussions
In this outpatient clinic-based study of subjects seeking obesity treatment, 50.8% subjects had used anti-obesity drugs. Approximately one-third of sub-jects who had normal weight or were overweight with no concomitant obesity-related risk factors took anti-obesity drugs although they were not sug-gested to do so. Approximately three-quarters of subjects did not adequately exercise or had a phys-ical activity level insufficient to prevent unhealthy weight gain. More than two-thirds of subjects had unrealistic weight loss expectations. This study is one of the few to provide comprehensive data for weight loss behavior in Taiwan.
Like other Asian countries, Taiwan has experi-enced rapid socioeconomic growth with dramatic lifestyle changes in recent decades[14]. The grow-ing availability of anti-obesity drugs has increased the involvement of physicians in treating obesity. Park et al. reported that primary care physicians tend to over-prescribe anti-obesity medications without allowing enough time for diet and exer-cise treatment to take effect in obese patients in Korea[6]. Approximately 90% of physicians report receiving requests by non-obese patients to pre-scribe anti-obesity medication, and 70% of those physicians subsequently comply. Hayton reported that most patients prescribed orlistat and sibu-tramine are not treated in accordance with NICE guidelines [5]. In accordance with these studies as well as previous studies in Taiwan, the cur-rent investigation suggested that the compliance among obese patient to the obesity treatment guideline is low [21]. Obesity treatment guide-lines suggest that clinical therapy should first address lifestyle changes such as modification of behavior, diet and exercise [20]. When lifestyle modification schemes are unsuccessful, drug ther-apy can be considered. Anti-obesity treatment by drug therapy has become common in the last 30 years. However, most anti-obesity drugs, such as fenfluramine-phentermine (fen-phen) [22,23], phenylpropanolamine (PPA) [24,25] and ephedra [26], have been withdrawn from the market due to serious adverse effects. Currently, only sibutramine and orlistat are FDA-approved for long-term obe-sity treatment. Sibutramine and orlistat were the most frequently used prescription weight loss drugs by the subjects in this study. Notably, 18.3% of respondents in this study reported using unproven weight loss drugs such as a cocktail therapy.
Table 3 Weekly amount of physical activity among subjects (n = 1030).
Physical activity All Women Men p-Value for2-test
No. % No. % No. %
VM (min/week) 0.15 0 638 61.9 484 63.3 154 58.1 1—149 124 12.0 94 12.3 30 11.3 ≥150 268 26.0 187 24.4 81 30.6 VMW(min/week) 0.02 0 490 47.6 382 49.9 108 40.8 1—299 244 23.7 179 23.4 65 24.5 ≥300 296 28.7 204 26.7 92 34.7
VM: physical activity of vigorous and moderate intensity and VMW: physical activity of vigorous and moderate intensity and walking.
Regarding drug safety, health care professionals must actively assist their patients in making appro-priate choices. Use of unproven weight loss drugs should be regulated by an government regulatory authority.
As in other studies, not all clients requesting obesity drugs were overweight or obese[6,27,28]. In this study, 40% of all respondents were females who did not meet the pharmacotherapy criteria (BMI≥ 27 kg/m2) proposed by National Institute of
Health[20]. Females were more likely than males to use weight loss drugs. Additionally, more females than males in each BMI category used anti-obesity drugs. Khan et al. indicated that females are four times more likely than males to report weight loss drug use[27]. In a population-based study, females were almost nine times more likely than males to report using a PPA weight loss product[29]. A pos-sible explanation for this gender difference is that females are more concerned than males with being thin and tend to be more dissatisfied with their bod-ies. Moreover, females tend to attempt weight loss at a lower BMI than males[30].
Total physical activity, expressed as minutes per week, was also categorized to determine the pro-portion of each sample meeting the CDC-ACSM physical activity guideline, which is often sim-plified as ‘‘at least 150 min/week of at least moderate-intensity physical activity’’ [10]. The
Healthy People 2000 objectives recommend
regu-lar sustained physical activity lasting 30 min, 5 days per week, particularly for weight loss [31]. In this study, 75.6% of female and 69.4% of male subjects were considered insufficiently active based on IPAQ recommendations. This rate is higher than those of other countries [15,16]and Taiwan[19]from gen-eral population. Furthermore, in a city population study in Brazil[32], the proportion of insufficiently active subjects was 43.1 and 47.8% in obese females and males, respectively, which is lower than that observed in the current study. However, the rate of this study is comparable to other studies from obese subjects. Regarding studies using instruments other than the IPAQ, a German study assessing physical activity by the Stanford 7-d Recall ques-tionnaire at entry into a weight loss intervention
Table 4 Anticipated weight loss among participants (n = 969).
All Women Men p-Value for2-test
No. % No. % No. %
Weight loss rate (kg/month) 0.015
<2 120 11.3 81 11.7 39 16.7
2—3 330 31.1 234 33.9 96 41.0
4—5 241 22.7 189 27.4 52 22.2
6—9 165 15.6 128 18.6 37 15.8
10— 68 6.4 58 8.4 10 4.3
Percentage of weight loss (%) <0.001
<10 47 4.4 24 3.3 23 9.5
10—19 222 20.9 148 20.4 74 30.5
20—29 326 30.8 225 31.0 101 41.6
Table 5 Logistic regression model for relationship between demographic characteristics and behaviors violating to recommendations. Anti-obesity drug use Inadequate physical activity (<300 min/week)
Unrealistic weight goal (>20% body weight) Anti-obesity drug use OR 95% CI OR 95% CI OR 95% CI OR 95% CI Gender F:M 2.3 1.7—3.2 1.7 1.2—2.3 5.8 3.8—8.8 2.2 1.6—3.2 BMI <24 1.0 1.0 1.0 1.0 24—26 (−) 1.3 0.8—1.9 1.0 0.6—1.6 3.4 2.0—5.6 1.1 0.7—1.8 24—26 (+) 1.9 1.0—3.4 1.6 0.8—3.3 2.0 1.0—4.0 2.0 1.0—4.0 27—29 2.0 1.3—3.1 1.1 0.7—1.8 5.7 3.4—9.5 1.6 1.0—2.6 30—34 2.2 1.5—3.4 1.0 0.7—1.6 9.2 5.3—15.7 2.1 1.3—3.3 ≥35 4.4 2.7—7.2 1.7 1.0—3.0 20.1 10.2—41.8 4.2 2.4—7.3 Age 18—24 1.9 1.0—3.4 2.0 1.1—3.8 4.4 2.1—9.3 1.6 0.9—3.1 25—34 2.2 1.4—3.4 2.4 1.5—4.0 2.2 1.3—3.8 2.0 1.2—3.3 35—44 1.6 1.1—2.4 1.9 1.2—2.9 2.1 1.3—3.3 1.5 1.0—2.3 ≥45 1.0 1.0 1.0 1.0 VMW < 300 min/week 1.4 1.0—2.0 VMW > 300 min/week 1.0 Weight goal > 20% 1.1 0.8—1.5 Weight goal < 20% 1.0
Adjusted for monthly income, educational level, marital status and obesity-related co-morbidity. VMW: physical activity of vigorous and moderate intensity and walking.
found that 61.5% of 109 obese subjects did not meet current physical activity recommendations, which is comparable to the finding of this study
[33]. Bish et al., in analysis of 2000 BRFSS data, found that only one-fifth of individuals attempting weight loss employed a strategy combining calo-rie reduction and minimum recommended physical activity level of 150 min/week [34]. Nevertheless, significant evidence indicates that overweight or obese adults unable to achieve this level of activity can still realize significant health benefits by par-ticipating in at least 30 min of moderately intense daily physical activity. Interventions targeting these physical activity levels are therefore important for improving health-related outcomes and facilitating long-term weight control. This finding is important for establishing public health guidelines for physical activity in obese patients. National guidelines are recommended to encourage physical activity among obese people.
In 1998, the National Heart, Lung and Blood Insti-tute recommended a 10% weight loss as a general goal of obesity management [20]. The 10% rec-ommendation was derived from the observation that obesity-associated morbidity is significantly decreased by moderate weight reduction, even if patients remain in the obese classification[35—37]. However, other studies have found that most obese
patients seeking treatment consider the recom-mended 10% weight loss a highly unsatisfactory goal[11,36]. Their minimum acceptable weight loss expectations are over twice as high as the 10% weight loss usually attained by the best evidence-based non-surgical weight loss treatments (e.g., behavior therapy and pharmacotherapy). Dalle Grave et al. indicated that baseline weight loss expectations are independent cognitive predictors of attrition in obese patients entering a weight loss program; the higher the expectations, the higher the attrition at 12 months[13]. The analyt-ical results of this study show that most subjects had unrealistic weight loss goals (weight loss≥ 20% of initial body weight). In a clinical setting, the decision to lose weight must be made jointly by the clinician and patient. Absolute commitment by the patient is crucial to success. Thus, distin-guishing between feasible and unrealistic goals is vital for avoiding overconfidence and false hopes which often lead to eventual failure and distress. This task might be particularly difficult in subjects seeking treatment for appearance-related reasons, those with lower BMI but greater body dissatisfac-tion and those with lower self-esteem. Therefore, unrealistic weight goals should be addressed at the very beginning of treatment. In this study, weight loss goals significantly differed between men and
women whereas actual weight loss achieved did not. Additionally, a previous study revealed only 27% of interviewed obese subjects initially had a realistic anticipated rate of weight loss[38]. The present study also illustrated the dramatic dispar-ity between patient expectations and professional recommendations and the need to help patients establish more modest weight loss goals.
This study had several limitations. First, the cross-sectional study design limits conclusions regarding causal relationships between charac-teristics and weight loss behaviors. Second, the participants in this study may not have accurately reported the anti-obesity products actually used, and the use of over the counter, herbal ther-apies and other unknown drugs may have been under-reported [39]. That is, the recall bias of this study may have underestimated their use in Taiwan. Third, only performed for at least 10 min duration per occasion were included. Finally, the analytical results were based on outpatient data. Consequently, the findings of this study should be extrapolated with caution to the general popula-tion.
However, this study conclusively demonstrated that patients seeking obesity treatment still inap-propriately use anti-obesity drugs despite the implementation of obesity treatment guidelines in Taiwan. Further, those seeking obesity treatment rarely receive recommended levels of physical activity. Like other Asian countries, Taiwan obese subjects often have unrealistic weight loss goals which may cause discouragement[40—43]. Further government initiatives and clinical studies of obe-sity are needed to reduce unhealthy weight loss behavior in the Taiwan population.
Acknowledgments
The authors would like to thank the Department of Health of the Republic of China, Taiwan for finan-cially supporting this research under Contract No. DOH93-TD-D-113-022(2). The physicians involved in this study are highly appreciated for their valuable assistance.
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