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Patients' reasons for weight loss and their relations to clinical weight loss outcomes in a comprehensive lifestyle intervention

Summary Objective Research suggests that individuals seeking weight loss treatment do so for a variety of reasons. Limited work has explored relations of reasons for weight loss to patient characteristics or to weight loss outcomes. The current study examined these relations. Methods The sample consisted of 588 patients in a 15‐week fee‐for‐service weight loss programme. Prior to the intervention, patients completed questionnaires including items on reasons for weight loss, demographic characteristics, and a variety of weight‐based characteristics. Patients' weight change outcomes were expressed as percent weight loss and also categorized into one of three previously described weight loss trajectories. Results The results of chi‐squared and t‐test analyses suggested that endorsement of health concerns, mobility concerns, or another person's recommendation was associated with higher body mass index (BMI) and older age. These reasons were more likely to be endorsed by White patients than Black patients and by male patients than female patients. Endorsement of doctor recommendation was more likely to be seen among Black patients than White patients. There was no significant relation of any weight loss reason with weight loss outcome. Conclusions While certain reasons for weight loss were more often cited by certain patient groups, no specific reason predicted a better or worse outcome.


| Intervention
The weight loss programme has been described in detail elsewhere. 12 Throughout treatment, patients were weighed at the start of each session and then met with an individual specialist (behavioural counsellor, exercise specialist, and registered dietitian) to discuss topics on lifestyle change, exercise, and nutrition. During weeks 1 through Robard Corporation, Mount Laurel, New Jersey]), and one very structured low-calorie meal. During weeks 9 through 15, patients consumed food-based meals. Patients could also consume one or two meal replacements during weeks 9 to 15, at their discretion.

| Measures
Prior to the initiation of treatment, patients completed a questionnaire packet containing demographic items and questionnaires assessing reasons for losing weight, psychosocial functioning, and weight-based characteristics.

| Reasons for weight loss
Patients' self-endorsed reasons for weight loss were established from a single item on the initial intake form. This item read: "Why are you trying to lose weight now?" Patients could select as many reasons as applied from the following choices: "appearance," "health," "mobility," "doctor suggested I lose weight," "other person suggested I lose weight (eg, friend, spouse)," and "other." The choices were nonmutually exclusive.
The "other" category was not included in any analyses.

| Demographic information
Patients filled out items assessing race, sex, and age on the initial intake form.

| Mood symptoms
The Beck Depression Inventory 13 (BDI-2) is a 21-item, self-report scale measuring characteristic attitudes and symptoms of depression over the previous 2-week period. Items are scored on a 4-point Likert scale. The BDI was used to assess patient mood prior to treatment.

| Statistical analyses
All analyses were conducted in IBM SPSS Statistics Version 25 and R

| Relations of reasons for weight loss to patient characteristics
Please see Tables 3 and 4 for a summary of chi-squared and t-test results. The endorsement of "person recommendation" as a reason for weight loss was associated with higher BMI and was more likely to be seen among White patients than Black patients and male patients than female patients. The endorsement of "doctor recommendation" was associated with higher BMI and older age and was more likely to be seen among Black patients than White patients and male patients than female patients. The endorsement of "mobility concern" was associated with higher BMI and older age and was more likely to be seen among White patients than Black patients and male patients than female patients. The endorsement of "appearance concern" was not associated with BMI, age, sex, or race. Although only 3% of our sample did not endorse health concern (18 patients), nonendorsement was associated with lower BMIs.
At pretreatment, the endorsement of "person recommendation" or "doctor recommendation" as a reason for weight loss was associated with lower pretreatment EBI score. The endorsement of "doctor recommendation" was also associated with higher BDI score. The endorsement of "mobility concern" was associated with lower PFS food not present, PFS food present, and PFS total score, with no differences on BDI or EBI scores. Neither the endorsement of "appearance concern" nor of "health concern" was differentially associated with pretreatment BDI, EBI, or PFS scores.
Posttreatment questionnaire results largely resembled those seen at pretreatment. The endorsement of "person recommendation" was again associated with lower EBI score, with no differences on PFS scores. The endorsement of "doctor recommendation" was not differentially associated with posttreatment EBI or PFS scores. The endorsement of "mobility concern" was associated only with lower PFS scores (PFS food not present and total scores). The endorsement of "appearance concern" was again not differentially associated with posttreatment EBI or PFS scores. The endorsement of "health concern" was associated with higher posttreatment EBI score; however, recall that only 3% of patients did not endorse this reason.

| Relations of weight loss reasons to outcome
Please see Table 4 and Figure 1 for multinomial regression results comparing reasons for weight loss across weight loss trajectory categories. As shown, the best fitting model included only the count of reasons for weight loss (ie, fit did not significantly improve by allowing each reason for weight loss to have its own slope). Within that model, the probability slope of the reason count is negative for weight loss groups 2 and 3, suggesting that a patient with more reasons for weight loss is less likely to experience either of the more successful weight loss trajectories. However, results of the multiple linear regression analysis showed that neither number of reasons nor specific reasons predicted total percent weight loss.

| DISCUSSION
The current investigation examined correlates of weight loss reasons among patients enrolled in a 15-week fee-for-service lifestyle intervention. Five nonmutually exclusive reasons for weight loss were examined: doctor recommendation, other person recommendation, mobility concern, appearance concern, and health concern. Large majorities of patients endorsed "health concern" and "appearance concern," roughly half endorsed "doctor recommendation" and "mobility concern," and a quarter endorsed "[another] person recommendation." Specific reasons for weight loss were not associated with total patient weight loss or with weight trajectory group, suggesting that among the reasons studied, no specific reason predicted weight change outcome. However, the total number of reasons endorsed was related to weight loss trajectory group, in a perhaps counterintuitive direction. Patients who endorsed more reasons were less likely to be in the more successful groups (more stable weekly changes with larger overall losses).
In contrast to the lack of observed relations to weight outcomes, results suggest that specific weight loss reasons are differentially associated with a variety of different patient characteristics. Those who were heavier and male tended to endorse recommendation from another individual (ie, doctor and/or nonphysician recommendation), mobility concerns, and health concerns as reasons for weight loss. Those who were older tended to endorse doctor recommendation and mobility concerns for weight loss. Doctor recommendation was more frequently endorsed by Black than by White patients, while mobility concern and other person recommendation were more frequently endorsed by White than Black patients. With the exception of the endorsement of doctor recommendation being reported more frequently by Black patients, these results suggest that, in general, when a reason for weight loss is endorsed, it tends to be associated with higher BMI and older age and is more frequently reported by White and male patients. Interestingly, we found that, at least in this sample, "appearance" reasons were endorsed with equal frequency regardless of sex, age, BMI, and race, perhaps suggesting that different groups of patients are equally motivated by appearance to seek weight loss services.
At pretreatment, the endorsement of doctor/person recommendation for weight loss was associated with lower usage of behaviours contributing to weight loss. The endorsement of doctor recommendation was additionally associated with lower mood. The endorsement of mobility concern was associated with lower hedonic hunger. The endorsement of person recommendation was associated with higher posttreatment use of recommended weight loss behaviours, while the endorsement of health concerns predicted lower use of those behaviours.  Additional literature suggests that different groups of patients are equally likely to receive a doctor's recommendation for weight loss, regardless of patient characteristics (ie, race and sex). 17 The present study implies that, while groups may not differ in the receipt of a doctor's recommendation, racial minority groups and those who are older may be more likely to report that receiving a doctor's recommendation contributes to their desire for weight loss.
The present study is not without limitations. The items that were used reflect the patients' beliefs that the reason played a role in their decisions to lose weight but do not assess whether the specific reason occurred (eg, doctor recommendation) and/or exists (eg, mobility problems). We cannot conclude, for example, that groups who did not endorse "doctor recommendation" for weight loss (ie, women, those with lower BMIs) have not received a doctor's recommendation to lose weight. Instead, patients not endorsing that reason may simply not see it as impacting their desire to lose weight. Another important limitation is that our sample was made up of individuals in a hospitalbased weight loss programme. We cannot therefore generalize our results to those seeking weight loss through other means, such as self-directed diets or commercial programmes. An additional limitation to the study is only patients who completed eight or more treatment visits were retained for analysis. Focusing only on those who completed 50% or more of the programme may have lost variability in weight loss outcomes.

| CONCLUSION
Results of the current investigation imply that the type of motivation