Adherence, behavior change, and visualization: A qualitative study of the experiences of taking an obesity medication

Abstract

Objective

Our objective was to examine patients' experiences of taking orlistat as a means to explore adherence and behavior change.

Method

We performed qualitative interviews with 12 participants who had taken orlistat in the past 2 years.

Results

Their experiences were described in terms of beliefs about the causes of their obesity, their motivations for taking orlistat, and highly visual side effects. These themes have implications for understanding adherence and behavior change. For some, the side effects led to nonadherence and absence of behavior change. These individuals seemed to be motivated by routine effects of being overweight, such as lowered self-esteem. In contrast, those who were motivated by a life crisis seemed to tolerate the side effects of the drug, leading to adherence. In turn, these highly visual side effects enabled them to make an explicit link between food consumed and weight, creating a shift in their beliefs about the causes of obesity and making behavior change more likely.

Conclusion

Orlistat use illustrates how treatment and illness beliefs interact to create both adherence and behavior change, particularly in the context of a life crisis and particularly when symptoms can be visualized.

Introduction

Most obese patients are managed through interventions involving a range of cognitive and behavioral techniques designed to facilitate changes in diet and exercise. Although some individuals lose weight with this approach, an analysis of the effectiveness of behaviorally based treatments suggests that, at 3- and 5-year follow-up visits, most regain weight, even up to their baseline weight [1], [2], [3]. In real terms, between 90% and 95% of those who lose weight regain it within several years [3], [4], [5]. In light of the general failure of behavioral interventions, some clinicians have turned to more medical solutions, including surgery and drugs. The surgical management of obesity has been endorsed by expert committees in the United States [4] and UK [6], but is only recommended for those with a body mass index of >40 kg/m² (or >35 kg/m², with complications of obesity) as long as they are made aware of the possible side effects. Surgery is, therefore, only available for the minority of obese patients. In contrast, drugs are available to a wider range of patients. Orlistat is one type of drug that acts on the gastrointestinal system and works by reducing fat absorption. Current recommendations suggest that it is used for patients who have a history of failed weight loss attempts using behavioral methods and who can demonstrate some degree of weight loss in the month before treatment [7]. Orlistat, however, has unpleasant side effects, including liquid stools, an urgency to go to the toilet, and anal leakage, which are particularly apparent following a high-fat meal as the drug causes the fat consumed to be removed from the body. Therefore, although orlistat is designed to work as a medical intervention, it probably also works by deterring unhealthy eating—an ‘antabuse effect’ [8].

Some research studies have addressed the effectiveness of these medical approaches to obesity treatment using quantitative designs and randomized control trials. The findings indicate that surgery can be effective for both weight loss and maintenance, that surgery brings with it a reduction in the risk factors for cardiovascular disease [9], [10], and that orlistat can also result in substantial weight loss [11], [12], [13], [14]. In addition, research has used a qualitative method to explore patients' experiences of surgery as a means to examine the mechanisms behind its success [15], [16], [17]. Recent results from these studies indicated that surgery not only has nonspecific effects created by weight loss (such as improved quality of life, confidence, and self-esteem) but also has specific effects caused by the actual operation. In particular, by enforcing a reduction in the amount of food that can be eaten, surgery seems to generate changes in the individuals' relationship with food and may help to reestablish a perception of control over their eating behavior [16], [17]. To date, however, no research has assessed the patients' experiences of taking orlistat in their attempt to lose weight. In this light, the present study used a qualitative design to explore the patients' experiences of taking orlistat as a means to promote an understanding of how and why this drug may be effective.

Orlistat, however, also raises some interesting psychological questions. First, given its unpleasant side effects and the fact that it is only effective if patients persist in taking it, the experience of taking orlistat is a useful window through which to explore the issue of adherence. Research shows that many patients do not adhere to their medication and can either show nonadherence or a form of partial adherence whereby the drug is used in a way that fits in with the patients' life [18], [19], [20], [21], [22]. For example, research on adherence to asthma medications showed that 73.2% of patients engaged in some form of partial adherence at some time [22]. The degree of adherence has been associated with a range of factors, including symptom perception and patients' beliefs about their illness and treatment [22], [23], [24], [25], [26], [27]. In line with this, the present study aimed to examine what factors determine an individual's decision to adhere to his or her prescribed medication. Second, the side effects of orlistat can be avoided if an individual changes his or her eating behavior and avoids high-fat foods. Orlistat is therefore also a useful tool to examine the process of successful and unsuccessful behavior changes. Behavior change has been studied extensively in terms of psychological factors that predict behavior, changes in behavior, and the development of interventions to promote change (e.g., [28], [29], [30], [31]). The present study aimed to explore changes in dietary behavior in the context of medication intake.