Attitudes Toward Obesity, Willingness to Lose Weight, and Treatment Preferences Among Overweight and Obese Saudi Adults

Background: Obesity has become a major health concern worldwide and is associated with several diseases and complications. Losing weight is an effective strategy to improve body mass index and prevent the complications of obesity. However, weight loss is dependent on the attitude of individuals toward obesity as well as their willingness to lose weight. Aim: To explore attitudes toward obesity, willingness to lose weight, and treatment preferences among overweight and obese Saudi adults. Methods: An analytical cross-sectional study was conducted among overweight and obese Saudis. We targeted adults aged 18 years and older, who visited family medicine clinics at King Abdulaziz Medical City for the National Guard in Riyadh, Saudi Arabia. The study was conducted from December 2020 to June 2021 using a self-administered questionnaire. Results: Of the 403 participants, 82.5% were dissatisfied with their current body weight. Controlling chronic disease was a major motive for improving body weight (53.2%), and exercise and diet were the most preferred strategies to lose body weight. Age was a determinant in the attitude and willingness of participants to lose weight (p = 0.0001). Conclusion: Participants in the current study reported high dissatisfaction rates about current weight and willingness to improve body weight. This should encourage healthcare providers to initiate weight status discussions and management with their overweight and obese clients.


Introduction
Obesity has become a major health concern worldwide. It is defined as "the accumulation of adipose tissue to excess and to an extent that impairs both physical and psychosocial health and well-being" [1]. Obesity has been linked to multiple preventable comorbidities and negative health outcomes. It is a known risk factor for non-communicable diseases like hypertension, type 2 diabetes mellitus, dyslipidemia, metabolic syndrome, coronary heart disease, and certain types of cancers [2].
Obesity rates are rising globally. Between 1975 and 2014, the prevalence of obesity (body mass index (BMI) ≥ 30 kg/m2) increased from 3.2% to 10.8% in adult men and from 6.4% to 14.9% in adult women [3]. In Saudi Arabia, epidemiological studies suggest that the prevalence of obesity is increasing. A community-based national survey found a progressive increase in obesity from 22% in 1990-1993 to 36% in 2005 [4,5]. A local study discussed current trends of obesity prevalence among adults. The study predicts that the overall obesity in Saudi Arabia will rise to 41% in men and 78% in women by 2022 [6]. In a national survey conducted in 2013, including 10,735 participants, Memish et al. found a 28.7% prevalence of obesity, with higher rates among females (33.5% vs. 24.1%) [7]. This increase in obesity rates can impair people's quality of life and adds considerably to national healthcare budgets [8].
Managing obesity as a chronic disease and setting interventional strategies aiming to reduce obesity prevalence is important. According to the health belief model, perceived personal susceptibility to disease can increase the likelihood of following the recommended actions and modify treatment-seeking behavior [9,10]. In addition, people with self-recognition of their obesity are more likely to try weight loss methods [11]. Therefore, an understanding of how people with overweight or obesity perceive their body image as well as their attitudes and willingness to lose weight is needed to provide effective and 1 2 2 2 The sample size was calculated based on Caterson et al., who found that 48% of the studied cohort were motivated to lose weight [12]. The calculated sample size was estimated to be 384 using a 95% confidence interval and a 5% margin of error; this was adjusted to 450 to compensate for the incomplete questionnaire. The sample size was calculated online using the OpenEpi epidemiologic calculator [13].

Data collection
Data related to participants' demographics were obtained from their electronic medical records. This included age, gender, and BMI. BMI was defined as weight in kilograms divided by height in squared meters (kg/m2). BMI categories were defined according to WHO cut-off points, i.e., 25.0-29.9 kg/m2 for overweight and ≥30.0 kg/m2 for obesity [14]. The obesity category was further subdivided into obesity class I (BMI: 30.0-34.9 kg/m2), obesity class II (35.0-39.9 kg/m2), and obesity class III (≥40.0 kg/m2).
Data related to study objectives were collected using a self-administered questionnaire. The questionnaire was developed by the authors after a literature review and considering study outcomes. It was developed in English and then translated into Arabic. The validity of translation was ensured by forwarding and backward translation. The questionnaire was reviewed by two experts for content validation. Questionnaire piloting was done on 20 patients; the piloted group was excluded from the study sample.
The questionnaire included five sections. The first section was for sociodemographic characteristics: educational level, marital status, employment status, and if they had any chronic medical or surgical conditions. Sections two, three, and four were about perception and attitudes toward obesity, participant awareness of obesity, and willingness to lose weight, respectively. Section five was about preferences for obesity therapies: participants were asked which weight loss strategy they would prefer, including "diet only, exercise only, exercise diet, bariatric surgery, taking weight reduction medications." Their preference was measured on a scale of "strongly preferred, preferred, neutral, not preferred, strongly not preferred." Moreover, if dieting was their preferred method to lose weight, then they were asked about their preferred dieting plan. Participants were approached by investigators and enrolled during their routine visits to the family medicine clinic in a convenient and nonprobability sampling method.

Data analysis
Data were analyzed using Statistical Package for the Social Sciences (SPSS; IBM Corp., Armonk, NY). All statistical tests were conducted at a significance level (alpha = 0.05). Quantitative variables were reported in the form of mean and standard deviation. Qualitative variables were in the form of frequency and percentages. Chi-squared was used to compare categorical variables.

Ethical considerations
Study approval was obtained from King Abdullah International Medical Research Center (KAIMRC), Ministry of National Guard, Saudi Arabia (IRB approval number: RC20/361/R; dated: August 16, 2020). Verbal consent was obtained from participants at the time of questionnaire distribution. Privacy and confidentiality were considered and completely protected; this was used only for research purposes. Data collection sheets were coded using three-digit serial numbers and were maintained by the co-investigator. Participants could not be identified after the collection of the datasheets. The study was conducted according to the principles of the Declaration of Helsinki. Ethical approval was obtained from parents of individuals younger than 18 years.
The questionnaire was distributed to 450 individuals, and 403 were completed and returned with a response rate of 89.5%. The characteristics of the 403 participants are shown in

TABLE 1: Characteristics of participants
The perceptions and attitudes of participants toward obesity are shown in Table 2. The majority (82.5%) were dissatisfied with their current body weight, 34.1% perceived themselves as obese, and 93% considered obesity a disease. Most (78.5%) thought that obesity is a result of a single cause. The most reported motivation to lose weight was to control or cure chronic conditions. The most reported barrier to losing weight was poor determination and will. Most participants (86.6%) had tried several times to lose weight.

Variables Total (%)
How do you perceive your weekly level of physical activity?   Table 3 represents the methods tried by participants for weight loss. The most common method was exercising (59%), followed by avoiding or eating less junk food and fast food (50%); less common methods were having bariatric surgery (3%) and taking prescription diet injections (2%).

TABLE 4: BMI and perception of participants
The preference of strategies to lose weight by participants is shown in Table 5. The preferred method was exercise and diet (83.1%), and the least preferred method was bariatric surgery (18.9%). When asked about the preferred diet to follow to lose weight, the most preferred type was decreasing unhealthy food and drinks. The least was intermittent fasting.  Bivariate analysis shows a significant difference between different BMI groups when asked if they think obesity jeopardizes their health, there were more affirmative answers as weight increased. In addition, the rate of dissatisfaction about current body weight increased as weight increased. Participants younger than 40 years of age were found to have more dissatisfaction rates about their current weight and were more motivated by cosmetic reasons and body shape to lose weight. They were more likely to try exercise for weight reduction relative to older participants ( Table 6).  Patients with chronic medical conditions, either single or multiple, consider their health restrictions (e.g., joint disease, anemia, heart disease, and lung disease) a barrier to improving their weight. Likewise, patients with multiple comorbid conditions are motivated to lose weight more by the idea that losing weight will relieve the active symptoms they currently have. In addition, educational level was associated with more awareness about the health risks of obesity ( Table 7).

Discussion
Our data indicate that most overweight or obese people are dissatisfied with their current weight. More than half of them think that they are either obese or very obese. A large majority knew that obesity is a disease. Most reported that obesity is caused by a single cause. In a similar study done in Lithuania, almost twothirds of 198 people with obesity were either unhappy or very unhappy with their current weight [15]. This attitude about obesity and the perception of it as a disease is encouraging because it forms a good basis for healthcare providers to initiate obesity management.

Saudi data from the ACTION International Observation (ACTION-IO) study by Alfadda et al. included 1,000
Saudis with obesity: 87% agreed that obesity has an enormous impact on health, and 68% considered it to be a chronic disease [16]. A similar rate was reported among American people with obesity [17].
Another local study evaluated Saudi females attending fitness centers and found that less than half of them underestimated their perceived body shape (40%). The majority (87%) were dissatisfied with their body shape, but, of these, 68% had normal weight [18]. This attitude, the dissatisfaction of people with normal weight with their body shape, is undesirable and may lead to unhealthy behavior.
The dissatisfaction rate was higher among people aged 40 or less, and the difference was statistically significant. This is understandable since younger people are expected to be more concerned about self-image and looks. As we might expect, the rate of dissatisfaction about current weight and perceived health risk of obesity both move proportionately to increased obesity levels. In a systematic review, aging was associated with decreased concern about body weight and less overweight or obesity self-perception [19]. This is important and should be considered when discussing obesity management with patients to encourage them to start weight management at an early age.
We found no gender difference in terms of dissatisfaction with current weight. This may be attributed to a nonmatching sample size of males with females (76 vs. 327). However, one study by Tsai et al. in the United States found that men are less accurate in their weight perceptions and weight dissatisfaction, i.e., their perception is less consistent with the actual body weight compared to women [20]. Similar findings were also reported among a Mediterranean adult population [21]. In a small local study, 18.4% of overweight or obese young males reported their weight as appropriate [22].
A previous Saudi study assessed the attitudes of adults toward obesity and showed that age, education level, and BMI were determinants for attitudes toward obesity [23] similar to our study. Age also significantly affected lifestyle-changing behavior, with younger people being more likely to change their lifestyle, as reported by Zelenyte et al. [15]. The willingness to lose weight was reported to be affected by BMI and gender, i.e., obese participants, especially men, showed a willingness to reduce weight more than men and women who are overweight [24]. A similar study in the United States found a significant difference between different ethnic groups in terms of self-recognition of obesity and views of obesity as a health problem, with whites being more likely to self-report obesity compared to Hispanics and African-Americans [11].
Of note, one-third of the participants did not think that they are at risk of health problems due to their current weight. This was more common among participants with low educational levels; it was statistically significant. This is worrying and patient education is needed to correct this misconception.
The vast majority of participants in this study perceived their intention and willingness to lose weight as strong. In comparison, a local study found that almost half of the investigated people with obesity were motivated to lose weight [13]. For comparison to international figures, we note the ACTION-IO study of 14,502 people with obesity across 11 countries; here, 48% were motivated to lose weight [12].
The major motive for our participants to lose weight was to control their chronic disease followed by relieving active symptoms. The main motives in other studies were different and included concerns about overall health, a desire to improve their look, to be more confident, to improve self-esteem, and to be more fit [16,25]. The difference here may be related to the type of study, which was community-based for the previous studies while this study analyzed visitors to family medicine clinics. About 63% were over the age of 40, and more than 70% of them have one or more chronic diseases. Considering age again, older participants were motivated by body shape and cosmetic appearance less than younger ones.
Most participants did not agree on the listed possible barriers to weight loss. This means no reported perceived barrier by the majority. The most frequent barrier (30% of participants) was poor determination and will. This is similar to the previous answer about perceived intention and willingness to lose weight where about 20% reported having weak intention and willingness. Another significant finding seen here is that almost 40% of participants with multiple chronic conditions considered health restrictions like joint disease, anemia, heart disease, and lung disease as a barrier to not losing weight. This must be considered when educating patients about lifestyle modifications and physical activities; these people need more appropriate types of exercise and control of disabling conditions.
In another local study, and in contrast to our findings, a lack of family support, unhealthy eating during social gatherings, and declining motivations were major barriers to weight loss [25]. Interestingly, a local study found that genetic factors were barriers to weight loss for 39% of participants [16]. Obesity is a multifactorial condition, and genetics certainly play a role; however, this has nothing to do with the ability and possibility to lose weight [26].
One-third of participants reported one or two serious attempts to lose weight, and about 60% had tried three or more attempts similar to findings by local and international studies [11,16,18]. In a local study done on overweight and obese women attending a diet clinic in Riyadh, the current visit to the diet clinic was the first trial to lose weight for 19.8% of participants, and 33.4% reported more than four attempts [27]. Lower figures were reported in an American study [18]. In a meta-analysis of 72 studies of 1,184,942 people from different Asian, European, and American countries, 42% reported at least one trial of weight reduction [28].
To succeed, it is particularly important for overweight or obese people to recognize their responsibility for weight loss and reaching a healthy weight. Here, we did not directly ask participants about their responsibility for obesity management; rather, a prior study found that 82% of respondents agreed that weight loss is their responsibility [17]. Healthcare workers (HCWs) play a key role in the initiation of obesity management and support people with obesity to lose weight. In a local study, 85% felt positive and 54% felt hopeful after a weight management discussion with HCWs [16]. This implies that more education and training for HCWs are needed for them to be confident and professional in discussing weight management with their patients.
The most preferred strategies to lose weight among our participants were exercise and diet (83.1%), followed by diet only (74.3%) and exercise only (73.2%). Similar findings were reported in two other studies [20,27]. This indicates that the major focus of participants was on exercise and diet. The major preferred plan related to diet control was to reduce the intake of unhealthy food and drinks. Food intake is perceived as a major cause of obesity. One study reported that food intake habits were a personalized bodyweight-determining factor with a strong impact on Saudi weight management [29]. This can be attributed to the fact that junk food consumption in Saudi Arabia is increasingly common [7].
Interestingly, weight reduction medication was the preferred way of weight loss by only 20% of participants. This contradicts the assumption that people with obesity and overweight may prefer easy and quick weightloss strategies.

Limitations
The non-probability convenient sampling way is considered a limitation. The number of males in this study did not match the number of females and there was no control group. Another limitation is that the study was not community-based, and this may limit the generalizability of the findings. Having no control group may be considered a limitation.