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Contents lists available at ScienceDirect

Patient Education and Counseling

journal homepage: www.elsevier.com/locate/pateducou

Health Care and Health Promotion

Weight loss drugs and lifestyle modification: Perceptions among a

diverse adult sample
S. Xing, L.K. Sharp, D.R. Touchette*
University of Illinois at Chicago Department of Pharmacy Systems, Outcomes and Policy, Chicago, IL, 833 South Wood St (MC 871), 60612-7230, USA

A R T I C L E I N F O A B S T R A C T

Article history: Objectives: Explore how adults from diverse racial and socioeconomic backgrounds perceive the use of
Received 16 February 2016 weight loss drugs (prescription, over-the counter, herbals and supplements) and lifestyle modification.
Received in revised form 26 September 2016 Methods: Individual, face-to-face, semi-structured interviews were conducted with persons presenting to
Accepted 8 November 2016
an academic hospital-affiliated outpatient pharmacy serving ethnic minorities and low income
individuals.
Keywords: Results: Fifty persons were interviewed, including 21 African Americans, 11 Hispanics and 17 low-income
Obesity
individuals (annual income <$20,000), of whom 33 self-reported as overweight or obese. Ever-users
Overweight
Ethnic minority
(14/50) and nonusers (36/50) of weight loss drugs expressed a belief in the importance of diet and
Pharmacotherapy exercise, but were not necessarily doing so themselves. Fear of side effects and skepticism towards
Weight loss efficacy of drugs deterred use. Some expressed concern over herbal product safety; others perceived
Qualitative study herbals as natural and safe. Drugs were often viewed as a short-cut and not a long-term weight
management solution.
Conclusion: A range of concerns related to the safety and efficacy of weight loss drugs were expressed by
this lower income, ethnically diverse population of underweight to obese adults.
Practice implications: There is need and opportunity for healthcare providers to provide weight loss advice
and accurate information regarding the safety and efficacy of various types of weight loss approaches.
ã 2016 Published by Elsevier Ireland Ltd.

1. Introduction herbals and supplements [9,10]. Unlike prescription and over-the-

counter (OTC) medications, these products do not undergo Food
Overweight/obesity is a highly prevalent public health problem and Drug Administration (FDA) evaluation for safety or efficacy,
affecting more than two-thirds of adult Americans [1]. Racial/ and adverse effects resulting in hospitalizations have been
ethnic minorities and low income individuals are disproportion- reported [11–14]. Use of prescription weight loss drugs is
ately affected [1]. To combat this epidemic, the American Medical estimated to be lower (3.5-4%) [7,15] than herbals and supplements
Association officially recognized obesity as a chronic disease [2]. (10–15%) [7,9,10,16]. Studies also suggest that Blacks and Hispanics
Physicians are urged to counsel all patients to achieve and tend to use more supplements and herbals and less prescription
maintain a healthy weight through lifestyle modification [3]. drugs for weight loss than Caucasians [15,17]. The underlying
However, the causes of obesity extend beyond excess food intake reasons are unclear, but public perspectives on the various weight
and low physical activity [4], making successful long-term weight loss options are likely one factor.
loss difficult [5]. Obesity guidelines recommend approved weight Studies originating from the United States (US) primarily focus
loss medications in addition to lifestyle modification [3,6]. on quantifying the patterns and frequency of weight loss drug use
As many as two out of every three Americans attempt to lose [18]. Research addressing patient perspectives towards weight loss
weight within a given year, contributing to a burgeoning weight drugs have been conducted outside the US, but included mostly
loss industry [7,8]. A variety of methods are used including diet Caucasian women or orlistat users [19–26]. Further insight into
reduction, exercise, meal replacements and commercial weight people’s perspectives regarding the selection of weight manage-
loss programs [5,7]. Americans also have convenient access to ment approaches in US samples can help healthcare providers
counsel patients, especially minorities and low-income individuals
most affected by obesity. This study explored perceptions towards
* Corresponding author. weight loss drugs (prescription, herbal/supplements, OTC) and
E-mail addresses: [email protected] (S. Xing), [email protected] (L.K. Sharp),
[email protected] (D.R. Touchette).

http://dx.doi.org/10.1016/j.pec.2016.11.004
0738-3991/ã 2016 Published by Elsevier Ireland Ltd.

Please cite this article in press as: S. Xing, et al., Weight loss drugs and lifestyle modification: Perceptions among a diverse adult sample, Patient
Educ Couns (2016), http://dx.doi.org/10.1016/j.pec.2016.11.004
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lifestyle management among adults from diverse racial and OTC, herbal, and supplement products. Weight loss drugs were
income backgrounds. further subcategorized as follows: FDA-approved weight loss
medications are considered “prescription”; FDA-approved OTC
2. Methods medication, of which orlistat is the only available medication, as
“OTC”; products made from botanicals or plants as “herbal”; and all
2.1. Recruitment and interviews non-FDA approved weight loss products that are not herbals as
“supplements”.
Participants were recruited January to May 2015 from an
academic hospital-affiliated outpatient pharmacy located in urban 2.3. Analysis
Chicago. The pharmacy serves a predominantly mixed income and
racial population. Adults were approached in the pharmacy Obese, overweight, normal weight, and underweight cutoffs
waiting area and introduced to the study. Those interested were were defined according to body mass index (BMI) 30, 25.0–29.9,
screened for eligibility in a private room. Eligibility included 1) 18 18.5–24.9, and 18.5 kg/m2 respectively, which was calculated
years of age or older, 2) English-speaking, 3) able to self-manage from the participants’ self-reported height and weight. Coding and
medications, and 4) willing to be audio-recorded. Self-identified analysis of transcripts were performed by all three authors. During
nonusers and ever-uses (past or current) of weight loss drugs were initial coding, transcripts were read by each author independently
interviewed. The University of Illinois of Chicago Institutional and then discussed as a group. General concepts were first loosely
Review Board approved this study and all participants provided assigned to categorize participant’s perceptions towards weight
signed informed consent. Participants were not reimbursed for loss drugs. These concepts were then iteratively regrouped under
participation. central emerging themes. After discussion, the three coders were
able to establish an initial coding dictionary and using this
2.2. Data collection dictionary, all transcripts were coded independently. The coding
dictionary was further refined and reviewed against transcripts
Individual, semi-structured face-to-face interviews were con- using the constant comparative method. An analytic memo
ducted by a trained researcher (SX). All interviews were audio- recorded points of agreement, disagreement, and interest.
recorded and transcribed verbatim. Interview questions were Consensus was reached by all coders by discussion and delibera-
developed based upon Ajzen’s Theory of Planned Behavior, a tion. Content analysis and coding was organized using ATLAS ti
theoretical framework that has been used to describe a variety of (Scientific Software Development GmbH; Berlin, Germany) [30].
volitional health behaviors including food choices, physical activity
and weight management [26–29]. Questions focused on people’s 3. Results
attitudes and beliefs towards weight loss drugs and diet and
exercise, including perceived efficacy and safety (Appendix A). 3.1. Participants
Self-reported demographics, height and weight were documented
after each interview. Interviews were conducted until all coders Approximately 30% of people approached declined to be
agreed that saturation of themes was reached. screened for eligibility due to lack of time or interest. Among
For the purpose of this study, the term “weight loss drug” was the 51 screened, 50 consented and 1 refused to be audio-recorded.
not operationally defined for participants during the interview to A total of 18 males and 32 females aged 24 to 66 years were
allow interpretation of the term from the participant’s perspective. interviewed (Table 1). Twenty-one (42%) participants self-identi-
In this manuscript, “weight loss drug” refers to all prescription, fied as African American and 11 (22%) as Hispanic. Fourteen (28%)

Table 1
Participant self-reported weight, height, demographics and use of weight loss drugs (N = 50).

Nonusers (n = 36) Ever-users (n = 14)a

Age (median, range) years 38 (24–66) 41 (30–65)
Gender (female) 21 (58.3%) 11 (78.6%)
Race/ethnicity
African American 12 (33.3%) 9 (64.3%)
Asian 6 (16.7%) 0 (0%)
Caucasian 10 (27.8%) 1 (7.1%)
Hispanic 7 (19.4%) 4 (28.6%)
Multiracial 1 (2.8%) 0 (0%)

Weight Categorya
Obese (BMI*  30.0 kg/m2) 10 (27.8%) 6 (42.9%)
Overweight (BMI*  25.0–29.9 kg/m2) 11 (30.6%) 6 (42.9%)
Normal weight (BMI*  18.5–24.9 kg/m2) 14 (38.9%) 2 (14.3%)
Underweight (BMI* < 18.5 kg/m2) 1 (2.8%) 0 (0%)

Income
<$20,000 12 (33.3%) 5 (35.7%)
$20,000 <$52,000 13 (36.1%) 5 (35.7%)
>$52,000 11 (30.6%) 4 (28.6%)

Personal use of weight loss drug

Herbal/Supplement 0 (0%) 13 (92.9%)
Prescription 0 (0%) 3 (21.4%)
Over the counter 0 (0%) 3 (21.4%)
*
Body mass index (BMI) was calculated based on self-reported weight and height.
a
Current and past users.

Please cite this article in press as: S. Xing, et al., Weight loss drugs and lifestyle modification: Perceptions among a diverse adult sample, Patient
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participants reported ever using a weight loss drug (ever-users). recommend to a friend or family member (see Question 3 in
Among the 14 ever-users, 13 (92.9%) had used herbals or Appendix A). Those who felt strongly against weight loss drugs
supplements in the past and one person was a current user. recommended seeing a doctor or lifestyle modification instead (11
Overall, 33 (66%) were overweight or obese based on self-reported nonusers and 2 ever-users). Among those who were willing to
weight and height. Among the 36 nonusers, 21 (58%) reported recommend a weight loss drug, suggestions were largely based on
being overweight or obese while among the 14 ever-users, 12 (86%) perceived safety and the extent of physician involvement. Three
reported being normal or underweight. participants recommended OTC over prescription weight loss
drugs. One felt that the OTC was not as “strong” and therefore less
3.2. Awareness and experience with weight loss drugs harmful; another wanted to avoid the hassle of going to see a
doctor; and the third thought that OTC was a good way to gauge the
Many participants spoke of weight loss drugs in general terms commitment of the person before using a prescription. The
without making clear distinctions among prescription, OTC, remaining participants generally fell into two categories: those
herbals or supplements until prompted. Some participants talked who thought that herbals were safe and natural versus those who
about using natural remedies, such as drinking lemon and water, thought that prescription drugs were safer because they were
when asked about weight loss drugs. Many referred to the clinically tested, regulated by the FDA, or monitored by the
formulation (e.g. “pill”, “tea”, “injection”) or perceived mechanism physician.
of action (e.g. “captures the grease”, “speed the metabolism”)
rather than the product name. Some nonusers had very little 3.4. Perceived risks and benefits
knowledge or opinions about weight loss drugs while others were
more knowledgeable and expressed strong opinions. Many Participants focused on the side effects of weight loss drugs.
participants were aware of weight loss drugs from the media Some nonusers were nonspecific and considered all weight loss
and through conversations with family or friends. Four ever-users drugs as unsafe, while other nonusers stated specific safety
and 3 nonusers had ever discussed weight loss options with a concerns. Nonusers’ opinions were based on information from
doctor. media sources or influential others, while ever-users’ spoke from
Ever-users who could recall the name of the drug they had personal experience.
taken used phentermine, orlistat, Garcinia Cambogia, lypozene, The most common side effects mentioned were cardiovascular-
acai berry, conjugated linoleic acid, GNC Burn 60, ephedrine, related. Nonusers voiced their apprehensions about anticipated
Hydroxycut, laxatives, testosterone pills, colon cleanser, and risks with both prescription and supplements: “elevated heart
human chorionic gonadotropin (HCG) pills. Two of the 14 (14%) rate”, “high blood pressure”, “heart attack”, “stroke”, “heart
ever-users were currently normal weight, 6 were obese (43%), and arrhythmias”, and “clots”. Ever-users talked about experiencing
6 (43%) were overweight. Eight of the 14 ever-users (57%) had palpitations and fast heartbeat. As an exceptional case, a 46 year-
dieted and/or exercised while using a weight loss drug, while 6 of old overweight African American male attributed his recent stroke
14 (43%) made no lifestyle modification. Duration of use varied to the “steroid type testosterone drug” he ordered from the internet
from just a couple of doses to use over a year; however, most for “weight loss and muscle building”. Other side effects attributed to
reported short term use lasting drug from weeks to months. Some weight loss drugs included organ damage, gastrointestinal side
participants tried several different weight loss drugs. One called effects (oily stools, diarrhea, vomiting), hyperactivity and insom-
herself a “repeat offender” who never used a weight loss drug for nia, and mood disturbances (anger, depression, anxiety). Although
more than a month, but took one when she was “trying to lose 5 or 6 not a common concern, three nonusers also mentioned the
pounds for an event”. Among the 13 past users, reasons for potential for drug interactions with other medications they were
discontinuation included cost, side effects, lack of results, reached taking.
weight loss goal, or a combination of these factors. The only current As for efficacy, participants recognized that the health benefits
user was a 40 year old obese Hispanic male who had been taking of healthy diet and physical activity extended beyond weight loss
Garcinia Cambogia for 6–12 months, initially for weight loss and alone. Some noted that although taking a weight loss drug might
then to prevent weight regain. result in weight loss, it might not necessarily improve health. The
majority believed that most weight loss drugs did not work, had
3.3. General attitudes and beliefs towards weight loss drugs and questionable efficacy, or that results were not maintainable. For
lifestyle modification many ever-users, the weight loss drug they had taken did not result
in weight loss. Any benefits observed from weight loss drugs were
Both ever-users and nonusers spoke of lifestyle modification as often perceived as short-term. Many expressed concerns about
essential to maintaining a healthy weight, including ever-users weight regain. For example, a 58 year-old overweight Hispanic
who did not alter their lifestyle while taking a weight loss drug. mother talked about her daughters’ struggles with maintaining
Many nonusers and a few ever-users expressed strong negative weight loss “I have two daughters, and they have heavy weight and
attitudes towards all weight loss drugs. However, a few nonusers trying to take some pills you know friends give you some pills,
who strongly supported lifestyle modification said that there and . . . they lost weight, yes. But then later, six months later, then
might be a place for weight loss drugs for those with medical they double."
conditions or more severe obesity. Nonusers who felt strongly A few participants carefully considered both the safety and
against prescription weight loss drugs tended to view them as efficacy of weight loss drugs. For example, a 29-year old obese
unsafe chemicals. Hispanic male nonuser worried about both the cardiovascular risk
Most ever-users and nonusers perceived weight loss drugs as and the lack of efficacy of weight loss drugs: ‘you’re going to lose no
adjuncts and not a replacement for diet and exercise. Many weight but you’re going to have a heart attack.’ In addition, some
participants also viewed weight loss drugs as a short-cut or quick- participants reported experiencing side effects but continued to
fix, which served as a deterrent for some. For others, the perception use the drug.
that weight loss drug was a short-cut acted as a temptation for use. People’s attitudes towards herbal weight loss drug were driven
Towards the end of the interview, participants were directly by perceived safety. Six nonusers and 7 ever-users recommended
asked which type of weight loss drug herbal supplements, herbal weight loss drugs because they viewed all herbals as natural
medicines OTC, or prescription medicine they would products that were safe to take. There were many comments such

Please cite this article in press as: S. Xing, et al., Weight loss drugs and lifestyle modification: Perceptions among a diverse adult sample, Patient
Educ Couns (2016), http://dx.doi.org/10.1016/j.pec.2016.11.004
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as “the odds of it [herbals] killing you are way less”, “anything herbal is weight loss products and educate on the risks and benefits of
natural”, “most herbal things is not potent and doesn’t have any type weight loss options. Given that some patients may think that
of major side effects”, and “I would see people either doing naturally weight loss medications are for short-term use only, information
do exercise or eating properly [sic] or maybe do some healthy herbal.” on the anticipated duration of use is also needed.
Two ever-users and 16 nonusers thought that prescription
drugs were safer or more effective given that these drugs are 4.1.1. Limitations
regulated, clinically tested, and used under a physician’s guidance. This was a single center study using a convenience sample and
These participants also viewed the physician as a professional with qualitative methods which collectively limit the generalizability of
the training and expertise to provide personalized weight loss the results. The study is further limited by the fact that very few
advice. Many trusted the doctor to recommend a suitable and safe prescription weight loss drug users were included. This likely
weight loss drug tailored to their own needs. Of the 14 participants represents the population studied, given that there is low
who used an herbal, supplement, or OTC weight loss drug, two had utilization of prescription weight loss drugs in low income and
informed their healthcare provider about use. minority populations. To gain an understanding of how people
perceived the risks and benefits of different types of weight loss
4. Discussion and conclusions drugs, we asked participants to recommend a particular type of
weight loss drug for a friend or family member. The framing of this
4.1. Discussion question may affect responses, as there is evidence that there are
self-other differences in decision making involving risk, where
To our knowledge, this is the first study that explored people may be more risk-tolerant for themselves versus others
perceptions towards multiple weight loss options within a [42–44]. In addition, other factors such as weight status, gender,
socioeconomically diverse population. By targeting those groups and race/ethnicity may also affect responses. Insights from a more
who are most impacted by excess weight, we provide valuable detailed analysis of these subgroups of patients would be possible
information that may be used to guide healthcare providers in in a study only with a larger sample and random or purposive
communicating with these individuals about weight loss options. sampling, topics for future study. Despite limitations, this is the
Views on weight loss drugs varied tremendously. However, most first report on weight loss drug perceptions among ethnic minority
respondents shared a concern for safety and effectiveness across all and lower income populations in the US. The findings may
options. Perceived risks associated with prescription weight loss generate hypothesis for future research.
drugs most often centered on cardiovascular effects. Some
mentioned specific prescription sympathomimetic drugs or 4.2. Conclusions
ephedrine supplements that were removed from the market.
The primary concern related to OTC and supplement weight loss Safety concerns, skepticism regarding efficacy, and the percep-
options centered on the lack of FDA review and uncertainty of their tion that weight loss drugs are a quick-fix reduced people’s
effects. acceptance of weight loss drugs as a viable and sustainable weight
Both ever-users and nonusers verbalized an awareness of the management option.
central role of lifestyle modification for weight management, a
finding that is consistent with the results of an U.K. study [19]. 4.3. Practice implications
However, many ever-users in this study reported taking a weight
loss drug without modifying diet or exercise. Reasons for the A deeper understanding of people’s perceptions towards weight
discrepancy between awareness and action are perhaps more loss drugs and diet and exercise will help facilitate shared-decision
complex than commonly investigated reasons such as environ- making and weight loss counseling. Physicians have an opportu-
mental barriers or lack of willpower [31]. Losing and maintaining nity to educate and correct misconceptions regarding the safety of
weight loss require conscious effort, self-monitoring, coping skills, weight loss drugs, including herbals and supplements, as well
regular physical activity, as well as social support [32,33]. Further discuss their intended duration of use.
effort to translate knowledge to action is an area of needed study.
Similar to findings from a UK study, many regarded herbal Disclosures
supplements as being more “natural”, which they equated to being
safer than prescription weight loss options [23]. This perception Daniel R. Touchette: Fellowship Director sponsored by Takeda
may contribute to decisions around disclosing supplement use to Pharmaceuticals; PI study involving unrestricted grant funds from
providers. In fact, some herbals are associated with serious Sunovion Pharmaceuticals. Takeda and Sunovion had no input or
cardiovascular problems [12–14,34]. Studies have found that influence on design, results, or interpretation of this study.
patient’s likelihood of disclosing use was strongest when patients Shan Xing: Medication Adherence Fellowship sponsored by
saw providers who attributed greater importance to asking about Takeda Pharmaceuticals USA, Inc. Takeda Pharmaceuticals had no
use [35] and when providers asked about use [36]. However, input or influence on design, results, or interpretation of the study.
physicians do not typically inquire about dietary supplement use Lisa K. Sharp: None.
[36,37].
Although many participants identified physicians as a knowl- Conflict of interest
edgeable source for weight management advice, few actually
reported seeking advice from their personal physician prior to Shan Xing is a Medication Adherence Fellow sponsored by
selecting a weight loss approach. This is consistent with prior Takeda Pharmaceuticals USA, Inc. during the time of this research
reports indicating that weight counseling during medical encoun- study. Takeda Pharmaceuticals had no input or influence on design,
ters is suboptimal [38] and that African Americans and Hispanics results, or interpretation of the study.
disproportionally receive less counseling even though they are Daniel Touchette is the Medication Adherence Fellowship
more likely to be overweight or obese [39]. Weight loss counseling Director sponsored by Takeda Pharmaceuticals and is the principle
is reimbursable under the Affordable Care Act for both commercial investigator for a study involving unrestricted grant funds from
and Medicaid enrollees [40,41]. Healthcare professionals can take Sunovion Pharmaceuticals. Takeda and Sunovion had no input or
this opportunity to inquire about the use of non-prescription influence on design, results, or interpretation of this study.

Please cite this article in press as: S. Xing, et al., Weight loss drugs and lifestyle modification: Perceptions among a diverse adult sample, Patient
Educ Couns (2016), http://dx.doi.org/10.1016/j.pec.2016.11.004
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