ORIGINAL CONTRIBUTIONS
Assessing Motivational Stages and Processes of Change for Weight
Management Around Bariatric Surgery: a Multicenter Study
Albert Lecube1,2 & Enric Sánchez1 & Ana Andrés3 & Carmina Saldaña4 & Maria José Morales5 & Alfonso Calañas6 &
Inka Miñambres7 & Silvia Pellitero2,8 & Fernando Cordido9 & Marta Bueno1 & Assumpta Caixàs10 & Nuria Vilarrasa2,11 & on
behalf of the Obesity Group of the Spanish Society of Endocrinology and Nutrition (GOSEEN)
# Springer Science+Business Media, LLC, part of Springer Nature 2019
Abstract
Introduction/Purpose The assessment of the patients’ motivation as a predictor of behavioral change via five stages (pre-
contemplation, contemplation, preparation, action, and maintenance) and four processes (emotional re-evaluation, weight
management actions, environmental restructuring, and weight consequences evaluation) of change.
Materials/Methods A total of 542 participants (251 waiting for bariatric surgery (BS), 90 undergoing BS, and 201 controls)
completed the Stages (S-Weight) and Processes (P-Weight) of Change in Overweight and Obese People questionnaires in a
multicenter cross-sectional study.
Results A higher percentage of subjects seeking BS (31.7%) were in the action stage (16.7% of post-BS patients, p < 0.001;
14.9% of controls, p < 0.001). The referred bodymass index (BMI) reduction was higher in subjects in active stages (3.6 ± 4.4 kg/
m2 in maintenance versus 1.4 ± 1.4 kg/m2 in contemplation, p < 0.001). In the P-Weight questionnaire, patients looking for BS
scored significant higher in the four processes of change than controls. In addition, a positive and significantly correlation
between BMI and the four processes was observed. In the stepwise multivariate analysis, BMI and the S-Weight allocation were
constantly associated with the four processes of change.
Conclusion Obesity is accompanied by a modifying behavioral stage, suggesting that subjects before BS are seriously thinking
about overcoming excess weight. To identify subjects on the waiting list for BS who will be more receptive to weight lost
interventions remains a challenge.
Keywords Bariatric surgery .Motivation stages . Obesity . Processes of change .Weight loss
* Albert Lecube
alecube@gmail.com
1 Endocrinology and Nutrition Department, University Hospital Arnau
de Vilanova, Obesity, Diabetes and Metabolism Research Group
(ODIM), IRBLleida, University of Lleida, Av. Rovira Roure 80,
25198 Lleida, Catalonia, Spain
2 Centro de Investigación Biomédica en Red de Diabetes y
Enfermedades Metabólicas Asociadas (CIBERDEM), Instituto de
Salud Carlos III (ISCIII), Madrid, Spain
3 Faculty of Psychology, Education Sciences and Sport Blanquerna,
Universitat Ramon Llull, Blanquerna, Barcelona, Catalonia, Spain
4 Department of Clinical Psychology and Psicobiology, Institut de
Neurociències, Universitat de Barcelona, Barcelona, Catalonia,
Spain
5 Endocrinology and Nutrition Department, Complexo Hospitalario
Universitario de Vigo, Vigo, Galicia, Spain
6 Endocrinology and Nutrition Department, Hospital Universitario
Reina Sofia, Córdoba, Andalucía, Spain
7 Endocrinology and Nutrition Department, Hospital de la Santa Creu i
Sant Pau, Universitat Autònoma de Barcelona, Barcelona, Catalonia,
Spain
8 Endocrinology and Nutrition Department, University Hospital and
Health Science Research Institute Germans Trias i Pujol,
Badalona, Catalonia, Spain
9 Department of Endocrinology, Hospital Universitario A Coruña, A
Coruña, Galicia, Spain
10 Endocrinology and Nutrition Department, Hospital Universitari Parc
Taulí, Sabadell, Catalonia, Spain
11 Endocrinology and Nutrition Department, Hospital Universitari de
Bellvitge-IDIBELL, L’Hospitalet de Llobregat,
Barcelona, Catalonia, Spain
Obesity Surgery
https://doi.org/10.1007/s11695-019-04001-4
Introduction/Purpose
The prevalence of obesity has rapidly increased during the last
three decades and has become one of the major public health
problems in the Western world, with enormous physical, so-
cial, economic, and psychological repercussions [1, 2]. This
result may be related to the lack of efficacy of the non-invasive
weight-loss approach to adult obesity [3, 4]. In fact, diet, ex-
ercise, and behavioral intervention have a very high long-term
failure rate as body weight appears to be physiologically
defended through hormonal, metabolic, genetic predisposi-
tion, and neural factors [5]. In addition, an adaptive decrease
in resting metabolic rate together with an increase in desire for
fatty foods follows weight loss [6, 7]. Therefore, the 95% of
people who try to lose weight regain and or even increase their
weight within a period of 5 years after dietetic, pharmacolog-
ical, or behavioral treatments [8]. Altogether, successful long-
term weight managing still depends on the ability of individ-
uals with obesity to change their behavior patterns. However,
many patients find it extremely difficult to initiate and main-
tain such changes, especially with respect to diet and exercise.
Similarly, the 20–25% of the subjects with obesity undergoing
bariatric surgery (BS) may have an inadequate weight and
metabolic response [9, 10].
How to identify subjects with poorer responses to weight-
loss interventions is still a challenge, both for the physician
and for the Health Administration. After identifying patients
who will fail to lose the expected amount of weight, physi-
cians may dedicate more aggressive intervention to these sub-
jects in which all efforts are needed to reduce disease severity.
Faced with this unpromising situation, the possibility of tai-
loring interventions and enhance results in the context of
weight management according to the patient’s motivation
has been pointed out in several studies [11, 12]. In this way,
the transtheoretical model (TTM) recommends assessing two
interrelated dimensions for the adequate assessment of behav-
ioral modification: stages of change and processes of change
[13]. The 1980s was the decade when TTM was proposed as
useful framework for enhancing the success of behavior mod-
ification interventions for smoking cessation setting [14–16].
But it was not until the late 1990s that it was considered to
apply the TTM also for the weight management [17–19].
BStages of change^ represent the temporal, motivational,
and constancy aspects of change, that range from pre-
contemplation (BAt the moment I’m not doing anything to
lose weight and I have no intention of doing anything over
the next 6 months^) to maintenance (BI’ve been making an
effort taken to maintain my weight, by dieting and/or exercis-
ing, for more than 6 months^) [20]. On the other hand, four
Bprocesses of change^ (emotional re-evaluation, weight
management actions, environmental restructuring, and
weight consequences evaluation) identify the way in which
people use overt and covert activities when they try to modify
problem behaviors related to weight management [21]. It has
been formerly recognized that progression through stages of
change is partially due to activation of processes of change
and explain the acquisition of healthy behaviors such as phys-
ical activity, eating patterns, or weight management [22, 23].
Gillison et al. in a pilot study including 108 participants with a
mean BMI at baseline of 32.7 ± 3.1 kg/m2, showed how pro-
cesses of change were found to mediate significant positive
impacts in weight loss and fiber consumption after 4 and
12 months of intervention [23]. Altogether, stages and pro-
cesses of weight management appear as a powerful predictor
of behavior change, positioning their assessment as an impor-
tant weight-management tool.
Two specific questionnaires to measure stages (S-Weight)
and processes (P-Weight) of change in the setting of weight
management have been developed and validated in Spanish
and English [20, 24, 25]. However, there is no clinical data
about the potential relationship between both questionnaires
and weight in patients awaiting BS and in patients who have
undergone bariatric procedures. To delve further into this re-
lationship, we designed a multicenter cross-sectional study to
evaluate stages and processes of change in a clinical sample of
subjects with morbidly obesity before surgery, patients who
lost weight post-BS, and controls without obesity.
Materials/Methods
Study Design and Participants
A total of 542 subjects were enrolled in the study between
September 2015 and June 2017, and three groups were well-
defined. The first one was recruited from the obesity units of
the hospitals and included 251 subjects that were on the
waiting list for BS at the time of their regular visits. All par-
ticipants had successfully passed the psychological evaluation
included in the BS protocol before proposing to participate in
the study. The second group was formed by 90 patients who
had undergone BS at least 18 months prior the study evalua-
tion. The third set of patients involved 201 subjects without
obesity (BMI < 30 kg/m2), that were matched by age and sex
with subjects in the obesity group; it was an opportunistic
sample including family and companions of the previous
two groups, and staff from the seven health centers.
Inclusion criteria to participate in this study were age at least
18 years old, absence of alcohol or sedative abuse, and non-
appearance of active malignancy.
The main clinical and sociodemographic characteristics
(educational level, incomes, marital status, and weight satis-
faction) of each group are shown in Table 1. The difference
between the maximumweight reported by participants and the
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current weight was calculated in addition to the change in
BMI (subtracting maximum BMI from current BMI of the
all groups).
Instruments: S-Weight and P-Weight Questionnaires
Participants completed the Spanish version of the Stages of
Change in Overweight and Obese People (S-Weight) and the
Processes of Change in Overweight and Obese People (P-
Weight) without any time limitation. Those on the waiting list
for BS and those who had undergone BS completed both
questionnaires during a routinely outpatient visit [26]. The
S-Weight is a questionnaire that consists of five mutually ex-
clusive items that aim to allocate participants to one of the five
stages of change for weight management proposed by the
TTM [13, 25]. Participants were asked to choose the response
that best corresponded to their current situation with respect to
losing weight: (1) pre-contemplation; (2) contemplation (BAt
the moment I’m not doing anything to lose weight but I’m
thinking about doing something over the next 6 months^); (3)
preparation (BDuring the last year I haven’t done anything to
lose weight but I’m planning to do something over the next
30 days^); (4) action (BI’ve been making an effort taken to
lose weight, by dieting and/or exercising, for less than
6 months^); and (5) maintenance.
The P-Weight is a 34-item questionnaire developed to as-
sess four processes of change in weight management [21, 24]:
(1) emotional re-evaluation (EmR, 13 items), (2) weight man-
agement actions (WMA, 7 items), (3) environmental
restructuring (EnR, 5 items), and (4) weight consequences
evaluation (WCE, 9 items). The answer to each item range
from 1 (strongly disagree) to 5 (strongly agree), with none of
the items being reverse scored. Scores for each one of the four
processes were calculated by summing the scores obtained on
items belonging to the same subscale, in which lower scores
reflect no use of a given process of change and higher scores
reflect the full use of that process [13]. To make scores from
the different subscales comparable, these scores are trans-
formed on a scale ranging from 0 to 100.
Statistical Analysis
Statistical analyseswere performed using IBMSPSS Statistics
for Windows, Version 20.0 (Armonk, NY: IBM Corp). All
variables followed a normal distribution according to the
Shapiro-Wilk test, so data were expressed as the mean ± stan-
dard deviation. Comparisons between groups were performed
using analysis of variance and the Student’s t test for contin-
uous variables, and the χ2 test for categorical variables. The
relationship between the continuous variables was examined
with Pearson’s linear correlation test. Four stepwise multivar-
iate regression analyses were used to explore the variables
independently related to the processes of change (EmR,
WCE, WMA, and EnR). Age, gender, BMI, education, gross
incomes, and weight satisfaction were the dependent vari-
ables. Significance of results was considered with p < 0.05.
Results
Participants on the waiting list for BS and post-BS showed a
higher prevalence of unfinished primary school than individ-
uals without obesity (22.3% and 30.0%, respectively, versus
7.9%; p < 0.001 for both comparisons) and a gross income ≤
18.000 € per year (44.2% and 52.2%, respectively, versus
24.4%; p < 0.001 for both comparisons). In addition, both
groups were also less satisfied with their current weight than
subjects without obesity (Table 1).
Table 1 The main clinical,
anthropometric, social, and
psychological characteristics of
the three groups assessed in the
study
Obesity
group
Bariatric
surgery group
Control
group
p
N 251 90 201 –
Age (years) 46.8 ± 10.2 49.0 ± 9.0 47.8 ± 10.1 0.171
Women, n (%) 176 (70.1) 70 (77.8) 140 (69.7) 0.132
BMI (kg/m2) 43.0 ± 7.7 31.1 ± 5.3 25.0 ± 2.9 < 0.001
Highest BMI (kg/m2) 46.9 ± 8.8 50.6 ± 6.9 26.9 ± 3.6 < 0.001
Change in BMI (kg/m2) 3.5 ± 4.5 19.9 ± 6.6 1.9 ± 1.7 < 0.001
Higher education, n (%) 29 (11.6) 13 (14.4) 88 (43.8) < 0.001
Married, n (%) 130 (51.8) 41 (45.6) 103 (51.2) 0.721
Gross income > 36,000 €, n (%) 19 (7.6) 4 (4.4) 72 (35.8) < 0.001
No dieting during the previous 12 months, n (%) 44 (17.5) 28 (31.1) 127 (63.2) < 0.001
Weight satisfaction: BFrom slightly to very
dissatisfied with my current weight^, n (%)
183 (72.9) 10 (11.1) 71 (35.3) < 0.001
Data are expressed as mean ± standard deviation or n (%). BMI, body mass index; BChange in BMI^, the
difference between the maximum BMI reported by the subject and the current BMI
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When the five stages of change for weight management
(S-Weight questionnaire) were assessed, patients seeking
BS placed themselves mostly in the action (31.7%) and
the maintenance (43.8%) stages. The percentage of sub-
jects with morbid obesity in the action stage was signifi-
cantly higher than the percentage observed among post-
BS patients and subjects without obesity (16.7%,
p < 0.001 and 14.9%, p < 0.001) (Fig. 1). This data agrees
with the fact that subjects on the waiting list for BS con-
firmed the initiation of more diets during the previous
year than the other two groups (between one and three
diets: 61.4% in subjects looking for BS, 35.5% after BS,
and 25.9% in individuals without obesity; p = 0.003 for
both comparisons). On the other hand, the 56.7% who
had undergone BS were in the maintenance stage and
were working to prevent relapse and consolidate the gains
attained during the action (43.8% in subjects with obesity
and 22.9 in participants without obesity; p ≤ 0.001 for
both comparisons) (Fig. 1). Conversely, individuals with-
ou t obes i ty were main ly a l loca ted to the pre -
contemplation stage, expressing no intention to change
their behavior in the future; this result was significantly
higher that the percentage detected in subjects with obe-
sity (39.9% versus 1.6%, p < 0.001).
When the difference between the maximum and the
current BMI was assessed in subjects on the waiting list
for BS, BMI decrement was higher in subjects who
claimed to be in the active stages (action, 3.5 ± 4.0 kg/
m2; maintenance, 3.6 ± 4.4 kg/m2) than in those in the
earlier stages (pre-contemplation, 1.5 ± 1.6 kg/m2;’ con-
templation, 1.4 ± 1.4 kg/m2) (p < 0.001 for all). However,
in the post-BS group, the maximum weight loss was
observed among those that referred to be in the pre-
contemplation stage (24.6 ± 6.7 kg/m2), whereas patients
in more active stages claimed a lighter response to surgery
(action, 14.9 ± 7.4 kg/m2; maintenance, 19.6 ± 5.8 kg/m2;
p ≤ 0.016 for both comparisons).
Data from the P-Weight questionnaire showed that pa-
tients in search for BS scored significantly higher in the four
processes of change for weight management than individ-
uals without obesity (Table 2). Subjects on the waiting list
for BS also scored higher in processes related to weight
consequence evaluation and emotional re-evaluation than
subjects who had undergone BS, without differences in
weigh t management ac t ions and env i ronmen ta l
restructuring processes. When participants who had under-
gone a previous bariatric procedure were excluded, a posi-
tive and significant correlation appeared between BMI and
the score of the four processes of change for weight man-
agement (Fig. 2). When the post-BS group was added, cor-
relations persisted with a lower correlation coefficient
(EmR, r = 0.537, p < 0.001; WMA, r = 0.408, p < 0.001;
EnR, r = 0.391, p < 0.001; WCE, r = 0.653, p < 0.001). In
addition, in this last group, BMI change was negative and
significantly correlated with a decrease in score in three
processes of change (EmR, r = − 0.423, p < 0.001; WCE,
r = − 0.312, p = 0.012; WMA, r = − 0.179, p = 0.153, and
EnR, r = − 0.355, p = 0.004) (Fig. 3).
Finally, the stepwise multivariate regression analysis
showed that BMI and the S-Weight allocation were constantly
associated with any of the four processes of change in weight
management. In addition, the educational level and the degree
with weight satisfaction also were related to EmR and WCE
(Table 3).
Fig. 1 Distribution of the stages
of change (S-Weight) in the three
groups assessed in the study. *p
value < 0.05 for the comparison
between patients waiting for bar-
iatric surgery obesity and patients
undergoing bariatric surgery. #p
value < 0.05 for the comparison
between subjects waiting for bar-
iatric surgery and control group
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Discussion
To the best of our knowledge, this is the first study to establish
that obesity is accompanied by a modifying behavioral stage,
suggesting that people on the waiting list for BS are aware that
a problem exists and are seriously thinking about overcoming
it. This data arises against the extended belief that overweight
people are lazy and lacking willpower about nutrition [27]. In
addition, their positioning in the Baction^ and Bmaintenance^
stages (the most advanced stages for weight management)
relates to the engaging in overt and covert activities that at-
tempt to modify problem behaviors related with weight ex-
cess. Our results seem to deny reality, in which most people
with obesity do not continue with weight loss programs, and
Fig. 2 Scatter plots showing the linear correlation between body mass index and the score obtained in the assessment of the four processes of change in
weight management in subjects without a previous bariatric procedure (n = 452)
Table 2 Scores in the four
Processes of Change in
Overweight andObese People (P-
Weight) according the three
groups assessed in the study
Obesity
group
(n = 251)
Bariatric
surgery group
(n = 90)
Control
group
(n = 201)
p value
Obesity versus bariatric
surgery group
p value
Obe s i t y v e r s u s
control group
EmR 81.2 ± 11.7 68.4 ± 16.7 53.9 ± 16.6 < 0.001 < 0.001
WMA 66.7 ± 14.7 65.5 ± 15.5 51.0 ± 16.8 0.494 < 0.001
EnR 56.4 ± 18.4 54.7 ± 18.9 38.6 ± 16.1 0.459 < 0.001
WCE 74.8 ± 15.4 58.5 ± 17.9 37.5 ± 14.4 <0.001 < 0.001
Data are expressed as mean ± standard deviation. EmR, emotional re-evaluation; WMA, weight management
actions; EnR, environmental restructuring; WCE, weight consequences evaluation
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only a few of those who do so actually lose weight. However,
this outcome may be influenced by factors such as the require-
ment of compliance of all visits in the hospital, the close
follow-up of the lifestyle behavior, and the demand to lose
weight before undergoing BS. Therefore, it is possible that
patients on the BS wait list were trying to present themselves
in a favorable light [28]. Participants in obesity treatment pro-
grams describe several barriers such as lack of time, frustra-
tion from preceding unsuccessful weight-loss efforts, and the
perceived cost of healthy foods [29]. Therefore, the way in
which to transform favorable motivational stages into clinical-
ly relevant results is still a major obstacle for healthcare pro-
fessionals taking care of subjects with overweight and obesity.
Although there is no yet established the best technique of
behavioral treatment, interventions require to be adapted to
reflect the needs of the patient population and local context
[30]. Individual and group sessions, in which participants are
invited to bring along a partner if they wish, with patient-
centered counseling techniques, and designed to teach key
facts about diet and physical activity, together with the skills
of action planning, problem-solving and self-monitoring [23,
31].
It has been suggested that motivational techniques may
promote weight loss by increasing adherence to weight loss
programs [11, 32]. The ability to assess the point at which
subjects with obesity are ready to change may help clinicians
tailor healthy interventions according to the patient’s motiva-
tion and address retention in the setting of weight manage-
ment. In this regard, the TTM proposes two interrelated do-
mains for the adequate assessment of behavioral change:
stages and processes [20, 33]. BStages of change^ represents
a motivational and constancy temporal trait that includes a
whole spectrum of subjects with obesity, ranging from those
without any intention to change their behavior in the foresee-
able future to those who are working to prevent relapse and
consolidate the healthy behavior [13, 20]. So, the identifica-
tion of the motivational stage of the patient with obesity
through the S-Weight questionnaire before any therapeutic
intervention seems mandatory to improve patient selection.
This tool will recognize patients in the action stage in which
Fig. 3 Scatter plots showing the linear correlation between BMI loss after bariatric surgery and the score obtained in the assessment of the four processes
of change in weight management (n = 90)
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we expect to achieve the higher percentages of weight loss. It
does not make much sense to start lifestyle changes when the
patient is in the pre-contemplation stage, where high drop-out
rates will occur.
Aweight loss program improves weight, but not for all sub-
jects, which leads to frustration in both patients and profes-
sionals. In our study, the application of the S-Weight
questionnaire identified that almost 25% of patients with obesity
seeking BS had allocated themselves to the three stages of
change that are related to the lack or only a small intention to
change their behavior (pre-contemplation, contemplation, and
preparation stages). While BS provides appropriate weight loss
in most individuals (defined as ≥ 50% excess weight loss), 20–
30% of subjects with obesity who undergo bariatric procedures
Table 3 Stepwise multivariate
regression analysis of variables
associated with the four processes
of change in weight management
Beta B (95% CI) p
Emotional re-evaluation
Weight satisfaction (from satisfied to dissatisfied) 0.320 2.6 (1.9 to 3.3) < 0.001
S-Weight (from inactive to active stages) 0.313 3.8 (2.9 to 4.7) < 0.001
BMI (Kg/m2) 0.312 0.6 (0.4 to 0.8) < 0.001
Education (from lower to higher education) − 0.078 − 0.6 (− 1.2 to − 0.1) 0.028
Gender (M/W) 0.014 – 0.678
Age (years) − 0.020 – 0.570
Gross incomes (from lower to higher income) − 0.021 – 0.610
Constant < 0.001
R2 = 0.760
Weight consequences evaluation
BMI (kg/m2) 0.554 1.2 (1.0 to 1.4) < 0.001
S-Weight (from inactive to active stages) 0.211 3.1 (2.1 to 4.1) < 0.001
Weight satisfaction (from satisfied to dissatisfied) 0.128 1.3 (0.5 to 2.0) 0.002
Education (from lower to higher education) − 0.086 − 0.8 (− 1.5 to − 0.2) 0.013
Age (years) 0.032 – 0.351
Gender (M/W) − 0.043 – 0.201
Gross incomes (from lower to higher income) − 0.045 – 0.258
Constant 0.297
R2 = 0.598
Weight management actions
S-Weight (from inactive to active stages) 0.473 5.1 (4.2 to 6.1) < 0.001
BMI (Kg/m2) 0.191 0.3 (0. 2 to 0. 5) < 0.001
Education (from lower to higher education) − 0.091 − 0.7 (− 1.3 to − 0.1) 0.034
Gender (M/W) 0.028 – 0.503
Gross incomes (from lower to higher income) 0.017 – 0.733
Age (years) 0.004 – 0.919
Weight satisfaction (from satisfied to dissatisfied) − 0.055 – 0.279
Constant < 0.001
R2 = 0.363
Environmental restructuring
S-Weight (from inactive to active stages) 0.323 4.1 (2.9 to 5.3) < 0.001
BMI (Kg/m2) 0.283 0.5 (0. 4 to 0. 7) < 0.001
Gender (M/W) 0.026 – 0.568
Age (years) − 0.016 – 0.727
Weight satisfaction (from satisfied to dissatisfied) − 0.050 – 0.361
Education (from lower to higher education) − 0.051 – 0.269
Gross incomes (from lower to higher income) − 0.052 – 0.269
Constant < 0.001
R2 = 0.255
BMI, body mass index; M, male; W, women
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do not reach this target [34]. This failure is considered multifac-
torial and has been associated with factors related both to the
healthcare center (experience of the surgical team, technical fac-
tors, preoperative patient education) and certain patient charac-
teristics (age, gender, baseline BMI, and presence of comorbid-
ities) [35]. However, these factors only partially explain the fail-
ure of the surgical option, and the insufficient weight loss post-
BS still appears as an unresolved clinical problem. As the BMI
decrement in our study was higher in subjects who claimed to be
in active stages, we suggest that the identification of the motiva-
tional stage through the S-Weight questionnaire may improve
patient selection and help to develop interventions targeted to
change this temporal motivational stage before surgical and
non-surgical treatment options. On the other hand, in the post-
BS group, the maximum weight loss was referred by patients in
the pre-contemplation stage. In this way, BS emerges as a good
technique not only for improvement of body health but also for
body satisfaction, reversing the states of change from action or
maintenance to pre-contemplation. It is reasonable to imagine
that patients nearest to their ideal body weight also have a better
self-esteem falling in the pre-contemplation stage. Finally, it also
should be pointed out that almost one-third of participants with-
out obesity were recognized to be in the action and maintenance
stages, reinforcing the idea that preoccupation with excess
weight also affects subjects without obesity.
The processes of change complement the assessment of the
stages of change by identifying the types of hidden and overt
activities and experiences in which individuals with obesity
engage when they attempt to modify behaviors problems [21].
The four freely correlated processes of change have shown
adequate psychometric properties and an adequate internal
consistency when were previously evaluated in clinical and
community adult samples from Spain and the United
Kingdom [13, 24]. In this regard, our data showed that as
BMI increased subjects engaged in a higher number of pro-
cesses of change for weight management, indistinctly related
to EmR, WCE, WMA, and EnR activities. In addition, the
biggest auto-referred decrement in BMI was positively corre-
lated with the activities related with the four processes of
change. Therefore, the assessment of stages and processes of
change in obese patients’ candidate to BS may be helpful to
health professionals to tailor interventions according to pa-
tient’s needs. Different strategies should be applied to promote
behavioral change and to engage patients to acquire or/and
maintain healthy habits that have been proved to be effective
in weight management [21]. Furthermore, to better BS results,
some patients in the action stage could be prioritized to the
detriment of those in pre-contemplation or contemplation
stages.
Some limitations should be managed when evaluating the
results of our study. As a cross-sectional study, we cannot
draw a causal relationship between both motivational stages
and processes of change for weight management and obesity,
and the potential result cannot be assessed in the setting of a
weight loss-related program. However, obesity is one of the
main relevant health problems in the twenty-first century that
has had frustrating outcomes in its non-surgical management;
therefore, our data support the development of interventional
strategies after considering the results of both questionnaires.
Second, the motivation for change in those participants on the
waiting list for BS can be influenced by demand, as BS re-
quires some modification of behavior as part of the conditions
to undergo surgery that could potentiate the positive results
obtained in our study. Third, the maximum weight assigned to
patients was sometimes reported by participants, and we are
not able to determinewhether the subjects responded sincerely
and objectively to the questions that were asked of them.
Therefore, a social desirability bias, as a tendency of survey
respondents to answer questions in a manner that will be
viewed favorably by other, cannot be ruled out. In addition,
both questionnaires should be interpreted solely as evidence
of the convergent validity of the scale and not as a measure for
psychopathology.
Conclusion
In conclusion, the obesity epidemic has resulted in increasing-
ly urgent calls for large-scale effective treatments and preven-
tion policies to attenuate the physical and psychological con-
sequences of excess weight [36]. The present study represents
a step forward in seeking these treatment goals for subjects on
the waiting list for BS who will be more receptive to weight
lost interventions. Our data suggest that patients seeking for
BSwho are not in the action and maintenance stages may be at
risk for suboptimal clinical outcomes after bariatric proce-
dures. Consequently, whether health professionals initiate ef-
forts to potentiate the patient’s motivational development, a
tailored medical approach resulting in sustainable weight loss
may be reached, particularly in the long-term. In this way, we
suggest introducing the assessment of stages and processes of
change in new therapeutic strategies and encouraging people
to advance through the motivational stages to effectively re-
duce weight and prevent weight regain. More research is
needed to effectively evaluate the connection between both
questionnaires and their definitive applicability, not only in
subjects previous BS but also in individuals with obesity seek-
ing for non-surgical weight loss programs.
Funding Sociedad Española de Endocrinología y Nutrición (SEEN) pro-
vided support in this research.
Compliance with Ethical Standards
Conflict of Interest The authors declare that they have no conflict of
interest.
OBES SURG
Ethics All procedures performed in studies involving human partici-
pants were in accordance with the ethical standards of the institutional
and/or national research committee and with the 1964 Helsinki declara-
tion and its later amendments or comparable ethical standards.
Informed Consent Informed consent was obtained from all individual
participants included in the study.
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