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Obesity is a major cause of morbidity and mortality in the United States, and its prevalence has been steadily increasing the last 20 years.1 At the same time, the frequency of dieting and other weight control practices may also be increasing. Among people with a body mass index greater than 27, almost two thirds of women and nearly half of men have tried to lose weight.2 Unfortunately, many adults who initially succeed regain most or all of their weight within 5 years.3
Given that many patients are unsuccessful in adhering to weight loss plans, it is important to understand the factors contributing to adherence. One factor may be patients' motivation for attempting to lose weight. In general, concerns about health appear to be the most common motivators, followed by concerns about appearance.4 However, women who desire to lose weight are more likely to do so in the hopes of improving their appearance, whereas men who wish to lose weight are more likely to be concerned about their future health and fitness.5 Research has been inconclusive about whether patients' motivations for losing weight affect their adherence to dieting and exercise regimens. One study found that overweight women who desired to change their appearance were more likely to adhere to an exercise regimen.6 However, in another study of adults of varying body weight, exercise adherence was associated with enjoyment, competence, and social interaction, but not with a desire to improve fitness or appearance.7
Furthermore, for both men and women, exercising and dieting to enhance attractiveness have been associated with body image dissatisfaction. Negative body image may deter obese individuals from exercising in public settings, such as a health club8; such individuals may also be less willing to seek medical or preventive health care services.9 Perhaps for these reasons, patients with an initially positive body image have been found to be more successful in losing weight.5
If a patient is motivated to change his or her behavior or lifestyle to lose weight, does it matter what drives this? The research suggests that the answer may be both yes and no. If the desire to lose weight is based on unhealthy or unrealistic goals, it may be medically and psychologically hazardous. Because there are risks associated with cosmetic procedures and various weight loss methods, the clinician should review these risks and discourage unrealistic expectations regarding their use.
Based on our experience in treating obese individuals and on these research findings, we suggest that the process of building obese patients' motivation should begin by emphasizing the health and fitness benefits of weight loss and maintenance. We find that we are more likely to persuade patients to change their attitude if there has been a recent event, such as a family health problem, that reinforces our message. We have also found that patients may be less motivated by relatively abstract medical constructs, such as blood pressure and lipid levels, than they are by physical symptoms, such as fatigue or exertional dyspnea.
As for sociocultural, appearance-based motivators for weight loss, we cannot close our eyes to their potency, but must use them cautiously. Patients who remain unconcerned about the health risks of their obesity may benefit from special emphasis on the other benefits of weight loss, such as increasing fitness and energy level. Failing this, motivation derived from extrinsic societal pressures may be better than no motivation at all. If our attempts to direct the patient's attention to the health, fitness, and energy-related benefits of weight loss have been ineffective, and the patient remains motivated primarily by appearance, this source of motivation should be encouraged, as to discourage it may squelch the patient's only motivation for weight loss.
Incidental social benefits of weight loss are often very powerful short-term motivators. However, these tend to be less effective at sustaining long-term lifestyle change because they often are geared toward transient events, such as losing weight for a wedding or some other social function. Positive changes in lifestyle that are not externally imposed, on the other hand, may be more likely to sustain themselves over time.
Although it is challenging for clinicians to uncover patients' motivators and determine how they will affect behavior, we believe that this is a professional obligation. As part of this process, we often share our opinions with patients about which motivators seem to work best, and those that other patients have found to be the most satisfying and sustainable. We encourage clinicians to dedicate time to discussing both health and appearance concerns with patients struggling to achieve and maintain a healthier weight. An empathic but frank approach will broaden what we can offer patients in their quest, not simply for the ideal body form, but for the ideal of the best health that each patient can achieve.
Cheskin LJ, Donze LF. Appearance vs Health as Motivators for Weight Loss. JAMA. 2001;286(17):2160. doi:10.1001/jama.286.17.2160-JMS1107-4-1
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