Reasons and Barriers to Lose Weight: Obese Adolescents’ Point of View

This work was carried out in collaboration between all authors. Author MCLP conceptualized and designed the study, contributed to acquisition and analysis of data, drafted the initial manuscript, and approved the final manuscript as submitted. Author JOH conceptualized and designed the study, reviewed and revised the manuscript, and approved the final manuscript as submitted. Authors HJGS and CRMF contributed to the interpretation of the data, critical evaluation of the manuscript, and approved the final draft of the manuscript. Authors CMSMF and MNLF revised the manuscript, and approved the final manuscript as submitted. Author WLP conceptualized and designed the study, carried out the analyses, drafted the initial manuscript, and approved the final manuscript as submitted. All authors read and approved the final manuscript. ABSTRACT Aims: To identify the reasons why obese Personal reasons for seeking weight loss treatment and barriers to losing weight were obtained by an individual semi-structured interview (8 questions) conducted by a psychologist. All individual interviews lasted approximately 20 min and were performed in a quiet room. Adolescents’ answers were semi-transcribed by the researcher and the content was anonymously analyzed in order to categorize the data. Results: The main reason for girls to start a weight loss program was to become healthy (39.47%), followed by to fit in clothes (30.26%), personal appearance (30.26%), and bullying (28.95%). Physical fitness (40.38%) was the most important reason to seek weight loss for boys, followed by to become healthy (36.54%), and bullying (25%). For both genders, the main barriers described were lack of self-control (47.37% - 36.54%), lack of social support (27.63% - 30.77%), and self-motivation (22.37% - 21.15%). Conclusion: Obese adolescents had several reasons for seeing weight loss. Overall, becoming healthy was the main motivation for weight loss and lack of self-control was the main barrier. This information can be used to help develop more effective weight loss strategies for obese adolescents.


INTRODUCTION
Clinically significant weight loss can be produced by increasing physical activity and decreasing energy intake. Weight loss outcomes are better the longer the therapy [1][2][3], but adherence to longer therapy requires higher levels of motivation from patients. Additionally, expectations for weight loss can affect adherence to therapy. In particular disparities between patients' goals and success in losing weight can reduce an individual's willingness to stay with long-term treatment [4].
It is important to note that intrinsic motivation (characterized by feelings of autonomy, selfdetermination and high sense of volition) has been found to be a powerful predictor of long term weight management in adults [5,6]. In adults, concerns about health appear to be the most common motivators, followed by concerns about appearance [7]. Women are more likely to be motivated by appearance, while men are more likely to lose weight to improve health and fitness [8]. A person seeking to lose weight primarily for appearance could have a different set of psychosocial characteristics and expectations than a person whose primary reason is to lose weight to improve healthy [9]. These characteristics and expectations could impact treatment success.
Overweight prevalence has increased from 4.0% to 13% among Brazilian adolescents over the last decade [10]. Very little is known about the reasons why obese and overweight adolescents want to lose weight, and their intrinsic an extrinsic motivators could vary greatly [11]. The aim of this study was to identify the reasons why obese adolescents seek weight loss therapy and what barriers they face to lose weight.

Participants
Seeking weight loss treatment in the Multidisciplinary Obesity Intervention Program outpatient clinic at the University of Pernambuco/Brazil in 2011. Adolescents were between the ages of 12 and 18 years with a body mass index (BMI) ≥95 th percentile [12], and pubertal stage 3 or 4 (Tanner scale) [13]. The study was formally approved by the ethics committee of the University of Pernambuco (154/09). Informed consent was obtained from all subjects and/or their parents.

Study Protocol
At first contact, a confidential 20-min semi-structured interview was conducted with each subject in a quiet room by a psychologist. The Interview contained 8 questions aimed to assess personal motives for seeking weight loss treatment and barriers to losing weight.
Questions asked during the interview 1. Why are you here today? Was it your decision or someone else´s? 2. On a scale from zero to ten, how interested are you in engaging in an exercise program and changing your eating habits? 3. What are your personal motivations to lose weight? 4. On a scale from zero to ten, how much do you believe you are able to change your lifestyle? 5. What are the main barriers preventing you from changing your lifestyle and weight? 6. How do you deal with the fact that you will have to give up things that you like in order to reach your goal? 7. Is it your main target to lose weight with this therapy? If you are not successful, what will you do? 8. What would make you drop out the therapy?

Anthropometric Measurements
Subjects wearing light clothing and no shoes were weighed on a ™Filizola scale to the nearest 0.1 kg. Height was measured to the nearest 0.5 cm by using a wall-mounted stadiometer (Sanny, model ES 2030). BMI was calculated as body weight divided by height squared.

Data Analysis
During the interviews, the researcher semi-transcribed the adolescents' answers and afterwards (on a different day) conducted an analysis of contents [14]. The aim to identify common themes which were used to code elements of the data. These were expressed as answer frequency (%). Differences between boys and girls were assessed by chi-square. Comparisons between genders for continuous variables (age and anthropometrical data) were made using independent T-test and presented as means ± SD. Significance were set at p≤0.05. All data were analyzed by STATISTICA 8.0 for Windows.

RESULTS
In this study, the sample was composed of 76 girls (59.4%) and 52 boys (40.6%). Table 1 shows anthropometrical characteristics of the subjects. No differences were observed in age between genders (p = .06). As expected, boys were heavier (p = .04) and taller (p = .00) than girls, however females showed higher BMI than males (p = .00).

Reasons to Lose Weight
Obese adolescents reported many reasons to seek weight loss therapy. The most frequent answer for girls was to become healthy (39.47%). This was followed by to fit in clothes (30.26%), personal appearance (30.26%), bullying (28.95%), and self-esteem (26.32%). Physical fitness (40.38%) was the most frequent reason that led boys seek therapy, followed by to become healthy (36.54%), bullying (25%), and self-esteem (19.23%). Boys and girls differed only in physical fitness (p = .00) and body shame (p = .04). It is important to note that only a few obese adolescents reported quality of life as a major factor for losing weight (3 boys and 0 girls) (Fig. 1). Table 2 presents some of adolescents´ responses to the questions.

Barriers to Lose Weight
The main barriers to seeking weight loss treatment in both girls and boys were lack of selfcontrol (47.37% -36.54%), lack of social support (27.63% -30.77%), and lack of selfmotivation (22.37% -21.15%). Difficulty of changing was reported by 19.23% of boys and anxiety was reported by 13.16% of girls (Fig. 2). Laziness was the only barrier that differed between genders (p = .04) with girls listing this more frequently than boys. Responses to the barriers questions are shown in Table 3.

Table 3. Examples of adolescents' responses to the barriers questions
Reason Example 1 Example 2 Self-control "I know I shouldn't eat too much, but when I start to eat at night I can´t stop" "…I tried to lose weight before, but quit. My brothers are obese too, and when they start to eat, I eat with them..." Social support "… My daddy says that it will not work, that I will not be successful…" "… it is hard exercising alone, because you don't have someone to talk to…" Selfmotivation "… definitely I have no willpower, but I want to believe.... talk is easy, but it is hard to do…" "…It is impossible to keep going, this time will not be different…"

DISCUSSION
We identified reasons why obese Brazilian adolescents seek weight loss therapy and their perceived barriers to success. The main results are: 1) Both boys and girls stated that the most important reason to lose weight is to become healthy; 2) Boys were worried about physical fitness while girls had profound body shame; and 3) Absence of self-control was the main barrier to success in obesity therapy for adolescents.
Improving health was the most frequent reason for losing weight in girls and the second most frequent reason for boys in the present study. Improving health seems to be important for adults and adolescents. It has been reported that motivation for weight loss in obese adults can divided into three broad categories: health (50%), appearance (35%) and mood (15%) [9]. However, men report health problems more as a trigger to lose weight than women [15]. We found that boys, much more than girls, are driven by a desire to become fit rather than just healthy. Improving fitness may not be a frequent reason for weight loss in adult men [16].
The desire to be more attractive and fitting in clothes were the next most frequent reasons for weight loss listed by girls. Personal appearance is often reported as a reason to lose weight [7]. Attractive individuals have advantages in employment, marriage, and other life outcomes [17,18], and are seen as happier, and more talented than other people. One study found that in obese 8 to 14 year-old children, a desire to ''fit in'' was an important reason for weight loss. Moreover, this desire stemmed not from a need to be ''perfect'', but from a desire to be ''normal'', to ''blend in'' with their peers so as not to be considered different and to suffer negative social consequence.
Improving self-esteem was listed as a frequent reason for weight loss for girls and boys. Obese children have consistently been shown to have lower self-esteem specifically related to their physical appearance and report higher levels of body dissatisfaction than non-obese children [19,20]. Lofrano-Prado et al. [21] showed that, in response to multidisciplinary therapy, obese adolescents improved self-esteem, quality of life and body image dissatisfaction. Those changes were not necessarily associated with weight loss.
Reducing bullying was an important reason for weight loss in girls and boys. Obese children who suffer from body dissatisfaction and low self-esteem may be at a greater risk of being bullied. When adolescents experience negative peer relationships and their weight status becomes the target of harassment, there can be negative short and long term effects [19].
Bullying is an aggressive behavior involving an imbalance of power between the bully and victim, and could take various forms, such as physical (e.g. hitting), verbal (e.g. calling mean names), social or relational (e.g. social exclusion and spreading rumors), or a relatively new form cyber bullying (e.g. bullying through computers or cell phones) [22]. Even slight deviations from "ideal body size" can trigger discrimination and weight bias from peers [20].
Lack of self-control was listed as the main barrier to lose weight in this population. Adults that have had previous experiences with weight loss treatment declare that the major obstacle to treatment adherence is lack of control while feeling hungry (71.3%), followed by staying motivated to keep the weight off (68.5%), and difficulty to eating properly (66.2%) [23]. Self-control could be influenced by the actions of peers, voices of authority, physical inability, access to sports facilities, the expense of ''healthy'' school meals and area of residence were all declared as barriers that influence on children's self-control [24], and are closely related with social support.
Lack of social support was another frequent barrier to success in this study. Social support is a key component of obesity treatment [23,25]. With adolescents, parents may unintentionally fail to provide this support, and even could create barriers to healthy eating behavior. Adults' perceive family eating habits (eating out, unhealthy cooking styles, and unavailability of healthy food) as a central obstacle to losing weight [12]. Children identify parents' support as essential in raising their self-efficacy and keeping them motivated. Without their parents they feel success would be unlikely [26].
In the present study, the absence of measures to validate the qualitative data and the fact that the content analysis was conducted by a single researcher can be considered as limitations that should be considered in the interpretation of the results.

CONCLUSION
These results add to the growing literature on treating adolescent obesity. Here we identified reasons for weight loss and barriers to success in obese Brazilian adolescent. We believe that a better understanding of these reasons and barriers could be useful in selecting the most appropriate approach to weight loss, and could eventually improve outcomes.

CONSENT
All authors declare that 'written informed consent was obtained from the patient (or other approved parties) for publication of this case report and accompanying images.

ETHICAL APPROVAL
The study was formally approved by the ethics committee of the University of Pernambuco (154/09).
for financial support; Thanks to Manoel Freitas by the support in the preparation of the figures. Special thanks to patients and their parents for the participation in this study.