A Concept Analysis: Adherence and Weight Loss

Authors


  • Laura E. Shay, PhD(c), RN, is a PhD student in nursing at the Uniformed Services University, Bethesda, MD.

Author contact: laura.shay@fda.hhs.gov, with a copy to the Editor: nursingforum@gmail.com

Abstract

There are numerous factors that influence an individual's ability to adhere to a healthy behavior. The literature cites common events that must take place prior to maintaining an exercise plan, a medication regimen, and a healthy diet. The purpose of this paper is to examine the concept of adherence in relation to weight loss using Walker and Avant's (1995) framework for concept analysis. This analysis revealed an extensive list of events or antecedents that may prove to be important when considering new strategies for weight management.

Introduction

The concept of adherence is widely discussed in the literature by healthcare disciplines including nursing, medicine, psychology, pharmacy, physical therapy, and nutrition. Essentially anyone who provides treatment, counseling, advice, or support considers adherence when determining outcome goals. The same is true for educators, lawmakers, and even parents. Adherence is a concept known to most law-abiding citizens. According to the Oxford Dictionary (1984), the verb to adhere is to give support or allegiance to a person, party, agreement, or opinion. It also means to behave according to a rule or undertaking, and to stick fast to a substance. The noun adherent is defined as a supporter or devotee of a party or activity. For the purpose of this concept analysis, the term adherence will be discussed as it relates to weight loss. In health care, the term adherence is generally associated with one's ability to maintain the behaviors associated with a plan of care. This often involves taking medications, keeping appointments, or changing health behaviors. Adherence is also referred to in the healthcare literature as compliance and maintenance. The opposite of adherence is often referred to as noncompliance or nonadherence. CINAHL and PubMed databases were searched for the key words adherence, compliance, and maintenance. Prior to 1996, the term compliance appeared more often than adherence. The use of the term compliance versus the term adherence has been debated for years. According to McDonald, Garg, and Haynes (2002), the term adherence is intended to be nonjudgmental, in that it is a statement of fact rather than of blame of the prescriber, patient, or treatment. Burke and Dunbar-Jacob (1995) describe the term adherence as emphasizing the mutual responsibility between patient and provider reinforcing the commitment of the provider to help the patient implement and follow their treatment plan. Murphy and Canales (2001) performed a concept analysis on the term compliance. Their analysis found that the concept of compliance is viewed by nurses as either evaluative, rationalization, and/or acceptance. Nurses who view compliance as evaluative are uncomfortable with the term compliance because they feel it is paternalistic and sets patients up to be viewed as “difficult” or “troublesome” if they are found to be noncompliant. Nurses who view compliance as rationalization understand the negative views related to the word compliance; however, they believe that it is appropriate to use it in some healthcare situations. And, nurses who view compliance as acceptance use the word compliance freely and without concern.

The perception of compliance from a patient's point of view was addressed by Thorne (1990). She found that patient's perceived noncompliance as an intentional and conscious decision not to adhere to professional advice. Schaffer and Yoon (2001) described adherence as an interactive patient–clinician relationship and compliance as a passive response to an authoritative relationship. Chockalingam et al. (1998) described both adherence and compliance as meaning the same thing: how well a patient follows and sticks to the management plan developed with her or his healthcare provider, which may include pharmacologic agents as well as changes in lifestyle (Chockalingam et al.).

The term maintenance is frequently used when describing adherence to health behaviors such as weight loss and exercise. A common model used to study health behaviors is the Transtheoretical Model of Stages of Change (Prochaska & DiClemente, 1983). This model is used to describe change as a process involving the progression through six stages: precontemplation, contemplation, preparation, action, and maintenance. The precontemplation stage is often characterized as the stage in which people are noncompliant, unmotivated, or not ready for treatment (Prochaska, 2001). On the other end of the spectrum is the maintenance stage, which is defined as the stage when an individual has achieved the targeted behavioral change for greater than 6 months and is working to sustain (adhere) to the change (Prochaska & DiClemente; Vallis et al., 2003).

The time period used to define maintenance and adherence varies throughout the literature. Speck and Harrell (2003) defined the ability to maintain regular exercise as participating in regular exercise for greater than 6 months. Phelan, Hill, Lang, Dibello, and Wing (2003) described weight loss maintenance as maintaining weight at or below baseline value for 2 years. Adherence in relation to cancer screening is based on whether or not an individual has had a screening test. For example, Fernandez, DeBor, Candreia, Wagner, and Stewart (1999) define nonadherence to mammogram screening guidelines as: (a) women 40 years of age or older who report never having a mammogram or (b) women who have never received a mammogram within the American Cancer Society–recommended interval for their age (Fernandez et al.). Women who are nonadherent to Pap test screening guidelines are defined as women who have never had a Pap test or if they had one, the lapse time was greater than a year since their last Pap test (Fernandez et al.).

In summary, the word adherence in the healthcare literature is also referred to as compliance and maintenance. The word compliance is viewed by some as paternalistic and is therefore being used to a lesser degree. The word maintenance is used more often when describing health behaviors such as exercise and weight loss. The amount of time used to define adherence, compliance, or maintenance varies from a single time point to greater than 2 years. The purpose of this paper is to examine the concept of adherence in relation to weight management in the adult population. In the literature, one finds the term maintenance used to describe the ability to remain at a targeted weight (e.g., one's ability to maintain weight loss) and the term adherence to describe the behaviors employed to lose weight (e.g., adhering to a low-calorie diet). The concept of adherence in relation to weight management will be analyzed using Walker and Avant's (1995) framework for concept analysis.

Antecedents Related to Adherence to Health-Promoting Behaviors

A pattern of antecedents related to an adult's ability to adhere to health-promoting behaviors was found in the literature. Antecedents are events or incidences that must take place prior to the occurrence of the concept (Walker & Avant, 1995). Samaras, Campbell, and Chisholm (1998) summarized many of these antecedents in the following statement: “Understanding the complex nature of non-adherence involves tackling issues such as motivation and self-esteem, ability to use available resources, physical barriers, and socioeconomic restrictions” (p. 195). These issues are consistently referred to in the literature as motivation, self-efficacy, access, environment, and socioeconomic status. Giannetti (2005) identified the following as key factors that predispose patients to nonadherence to therapeutic regimens: complex dosing regimens, sensory anomalies, age, lack of social support, lack of knowledge, psychiatric diagnosis, and financial problems. Lopez, Burrowes, Gizis, and Brommage (2007) found knowledge, socioeconomic status, and family support to be important factors influencing dietary adherence to a renal diet. Boyette et al. (2002) explored exercise behavior in adults over the age of 60 years through an extensive review of the literature. They narrowed their findings down to nine antecedents that they identified as incentives and/or obstacles to exercise initiation and adherence: age, gender, ethnicity, occupation, educational level, socioeconomic status, smoking status, and past exercise participation. The research studies and literature summaries focused on adherence to diet, exercise, and medication regimens for chronic diseases such as diabetes and hypertension. For the purpose of this concept analysis, antecedents that focus on adherence to a health-promoting behaviors are reviewed. Table 1 depicts antecedents with a brief description of each. These antecedents are consistently addressed in the literature when describing adherence to health-promoting behaviors.

Table 1. Antecedents Related to Adherence to Health-Promoting Behaviors
AntecedentDescription
Self-efficacy• Exercise adherence in older adults testing the WALC (Walk; Address pain, fear and fatigue; Learn about exercise; Cue by self-modeling) intervention found that the stronger the individual's self-efficacy the more likely they adhered with a physical activity (Resnick, 2002).
• Speck and Harrell (2003) report that self-efficacy is consistently associated with increased levels of physical activity.
• Self-efficacy is reported to affect dietary adherence (Tinker et al., 2002).
• Schutzer and Graves (2004) found that the best adherers to regular exercise have higher levels of self-efficacy.
Outcome expectation and perceived value• The lack of belief that an intervention will be successful decreases adherence (Fodor et al., 1998).
• Resnick (2002) reports that if an older adult has high self-efficacy expectations, but does not believe the exercise will improve health, strength, or function, then it is unlikely they will adhere to a regular exercise program.
• Nonadherence to medications may be associated with the perception that the treatment may have limited benefit (Schaffer & Yoon, 2001).
• People who demonstrate better adherence to dietary interventions may believe in the diet–cancer connection (Tinker et al., 2002).
• Kavookjian et al. (2005) found that the diabetics who decided to adhere to the diet regimen were most highly influenced by their desire to prevent their diabetes from getting worse.
• Data from the National Weight Control Registry demonstrated that individuals who had medical reasons for weight loss had better initial weight losses and maintenance (Gorin, Phelan, Hill, & Wing, 2004).
Prior relapse• The number of times an individual has relapsed from a program of regular exercise may be a predictor of maintenance (Speck & Harrell, 2003).
• Success for most individuals comes after several relapses (Schachter, 1982).
• 91% of participants in the National Weight Control Registry report previous unsuccessful attempts to lose weight (Klem, 2000).
Time• A study addressing medication compliance in diabetics found that patients reported “having a busy life” as one of the reasons for not being compliant (Lee & Leung, 2003).
• Many elderly view the adoption of moderate physical activity time consuming (Chao, Foy, & Farmer, 2000).
• The Behavioral Risk Factor Surveillance System database (1999–2000) found lack of time to be a barrier to physical activity (Brownson, Baker, Housemann, Brennan, & Bacak, 2001).
• In a survey conducted in the European Union (1995–1996) lack of time was the most frequently mentioned reason subjects did not adhere to nutrition advice (Lappalainen et al., 1997).
Environment• The physical environment (lack of sidewalks, parks, recreation and fitness centers, high crime rates) can present as potential barrier to exercise adherence (Humpel, Owen, & Leslie, 2002; Schutzer & Graves, 2004).
• The food choices people make are limited to the food available to them. Lack of private transportation and supermarkets in low-wealth neighborhoods may create a disadvantage when attempting to achieve a healthy diet (Morland, Wing, Diez Roux, & Poole, 2002).
Social support• Married couples maintain physical activity levels better than single participants in research studies (Speck & Harrell, 2003).
• Results from the feasibility studies with the Women's Health Initiative Dietary Modification study arm which showed that attending group sessions strongly predicts the adherence to a low-fat diet (Fodor et al., 1998).
• Lack of social and family support was reported as a contributor to poor adherence to antiretroviral treatment (Simoni, Frick, Pantalone, & Turner, 2003; Vervoort, Borleffs, Hoepelman, & Grypdonck, 2007).
• Participation in health-promoting behaviors within a community setting has also been demonstrated to improve adherence (Chyun, Amend, Newlin, Langerman, & Melkus, 2003).
• Lack of adequate social support was found to be associated with nonadherence with therapeutic regimens for chronic heart failure (Stromberg, Brostrom, Dahlstrom, & Fridlund, 1999).
Knowledge• Decreased knowledge is a factor in poor medication adherence and low levels of exercise (Chyun et al., 2003).
• A patient that is well informed is more likely to adhere than one lacking information (Chockalingam et al., 1998).
• Patients with a greater understanding of their disease and management plan will have an increase in their adherence (Feldman, Bacher, Campbell, Drover, & Chockalingam, 1998).
• Lack of knowledge of low-cholesterol foods is one of the primary reasons patients listed why they did not follow a cholesterol treatment plan (Goebel, Bailony, Khattak, & Gress, 2006).
• Researchers suggest that lack of knowledge is a major barrier in diet adherence (Chung et al., 2006).
Socioeconomic status• Nonadherence to medication regimens is complicated by high costs of pharmaceuticals (Chockalingam et al., 1998).
• In a study looking at adherence to consuming the recommended five servings of fruits and vegetables a day, it was reported that the high cost of this type of food was one reason for poor adherence (Neill, Wise, & McLeish, 2000).
• Low income was one of the factors associated with poor adherence in the Women's Health Imitative Dietary Modification Trial (Women's Health Initiative Study Group, 2004).
Perception of harm/adverse effect• Fear of harm or an adverse event has been shown to decrease participation in exercise and medication compliance (Tinker et al., 2002).
• Adverse events influence the ability to sustain behavior change (Whitlock, Orleans, Pender, & Allan, 2002).
• Adverse events from medication was one of the reasons for decreased adherence in diabetic and hypertensive patients (Hamilton, Roberts, Johnson, Tropp, & Anthony-Odgren, 1993; Lee & Leung, 2003).
• In a study looking at adherence to consuming the recommended five servings of fruits and vegetables a day, subjects reported poor taste as a reason for not complying (Neill et al., 2000).
Active participation• Self-measurement of blood pressure enhances adherence to blood pressure management (Chockalingam et al., 1998; Fodor et al., 1998).
• A patient-centered counseling model enhances long-term dietary adherence (Rosal et al., 2001).
• Patient involvement in medical decisions has been shown to impact adherence (Cooper, Hill, & Powe, 2002).
Provider influence• Caring by healthcare providers was identified as influential to adherence with blood pressure treatment (Chyun et al., 2003).
• A key issue in medication adherence is a good relationship with the clinician allowing for open communication about treatment concerns, goals, and potential barriers (Schaffer & Yoon, 2001).
• Some of the factors related to poor adherence can be attributed to providers’ lack of available time for counseling or a lack of interest that the intervention can be successful (Chockalingam et al., 1998).
• Elderly are more likely to change their level of activity as a result of conversations with their physicians (Schutzer & Graves, 2004).
• Recommendations from healthcare providers to follow a sodium retracted diet is fundamental to patient adherence (Chung et al., 2006).
Mental status stress level• Poor mental health status is known to be associated with poor adherence to medical regimens (Tinker et al., 2002).
• Better adherence to dietary interventions may occur in individuals who experience a fewer number of stressful events (Tinker et al., 2002).
• Depression was found to be a major contributor to nonadherence to hypertension treatment (Siegel, Lopez, & Meier, 2007).
• In a primary care population, major depression was associated with behaviors that are difficult to maintain (e.g., exercise, diet, medication adherence) (Lin et al., 2004).
Motivation• A study looking at factors affecting exercise adherence at a worksite wellness program found that self-motivation was one of the major contributors to a person's adherence to the program (Bungum, Orsak, & Chng, 1997).
• Brownson et al. (2001) in their analysis of the Behavioral Risk Factor Surveillance System database (1999–2000) found lack of motivation to be a barrier to physical activity.
• Lack of motivation is a major barrier to change and is necessary for effective long-term care (Haslam & James, 2005).
Perceived goal attainability• The association between complicated dosing regimens and decreased medication compliance is reported throughout the literature (Chockalingam et al., 1998; Feldman et al., 1998; Lee & Leung, 2003; Schaffer & Yoon, 2001; Simoni et al., 2003).
• In a study looking at adherence to consuming the recommended five servings of fruits and vegetables a day, subjects reported that they did not comply because they felt that the amount was excessive (Neill et al., 2000).
• Lower intensity exercise programs have been shown to have higher adherence rates than programs with higher intensity exercises (Bungum et al., 1997).
• A major perceived barrier to effective diabetes self-management was frustration from lack of glycemic control and continued disease progression despite adherence (Nagelkerk, Reick, & Meengs, 2006).
• Data from the National Weight Control Registry demonstrated that individuals who had kept their weight off for 2 or more years had a marked increase in the odds of maintaining their weight over the following year (Wing & Phelan, 2005). Participants who gained the most weight in year 1 were the least likely to re-lose weight the following year (Wing & Phelan, 2005).

Critical Attributes to Adhering to or Maintaining Long-Term Weight Management

Obesity in the United States is a public health epidemic and is the second leading cause of death from modifiable risk factors, after tobacco use (Mokdad, Marks, Stroup, & Gerberding, 2004). Between 1980 and 2002, the prevalence in obesity doubled in adults and tripled in children (Flegal, Carroll, Ogden, & Johnson, 2002; Flegal, Graubard, Williamson, & Gail, 2005). The most current estimate of overweight and obesity calculated from the National Health and Nutrition Examination Survey found that the prevalence of overweight among children and adolescents and obesity among men increased significantly from 1999 to 2004. For women, there was no overall increase in the prevalence of obesity; however, when the data for women are analyzed by racial/ethnic group, there is a steady increase in the prevalence of overweight and obese seen with non-Hispanic Black women, and for Mexican American women (Ogden et al., 2006). To date, many interventions have been successful in producing short-term improvements in diet, physical activity, and weight, but few, if any, have been found to produce long-term behavioral change (Hill, Peters, & Wyatt, 2007). Research has placed greater emphasis on initiating and obtaining weight loss even though only an estimated 21% of obese/overweight persons are successful at achieving long-term weight loss (Ayyad & Andersen, 2000; Wing & Hill, 2001). “Maintenance is a critical stage, and much less is known about interventions to sustain change over time until it becomes an integral part of a lifestyle” (Pullen & Noble Walker, 2002, p. 176). Fortunately, a group of researchers recognized this problem and, as a result, developed the National Weight Control Registry (NWCR) as a way to study weight loss maintenance. The NWCR is the largest database with the most detailed information on successful adult weight maintainers. The NWCR was founded in 1994 by Drs. James Hill and Rena Wing as a way to investigate the behaviors and characteristics of individuals who have been successful at achieving long-term weight loss (Wing & Phelan, 2005). To be eligible, individuals must be 18 years old or older, have lost at least 13.6 kg (30 lbs), and have maintained their weight loss for at least 1 year. Recruitment was done through public service announcements and local and national media. Registration was by telephone and informed consent and questionnaires were completed through the mail. A healthcare provider's documentation of the weight loss was obtained when possible. The database currently contains over 4,000 subjects. The average age is 46.8 years, 77% are women, and 95% are Caucasian (factors contributing to the disproportionate recruitment of Caucasian women is unknown; however, it is discussed as a study limitation by the researchers). The average reported weight loss is 33 kg (~73 lbs), and the average duration of weight loss maintenance is 5.7 years (Wing & Phelan). Since the start of the program, the data have consistently demonstrated the following critical attributes for successful weight loss maintenance: (a) eating a low-fat, low-calorie diet; (b) frequent monitoring of weight of at least once a week; and (c) 1 hr of moderate-intensity physical activity per day. In addition, most registry members reported eating 4.7 meals or snacks a day and 78% reported eating breakfast daily (Wyatt et al., 2002; Wing & Gorin, 2003; Wing & Phelan).

Consequences and Empirical Referents

Consequences “are those events or incidents that occur as a result of the occurrence of the concept” (Walker & Avant, 1995, p. 46). The consequences that result from adhering to or maintaining a targeted weight loss are numerous. Even small weight losses can reduce obesity-associated risk factors for chronic diseases such as diabetes, hyperlipidemia, and hypertension (Greenwood, 2007; McInnis, 2003; Serdula, Khan, & Dietz, 2003). An additional benefit to weight loss is a reduction in joint pain associated with osteoarthritis (McInnis). Over 90% of subjects sampled from the NWCR reported improvements in their overall quality of life, energy level, mobility, general mood, and self-confidence (Wing & Hill, 2001; Wing & Phelan, 2005).

The empirical referents of a concept are classes or categories of actual phenomena that by their existence demonstrate the occurrence of the concept (Walker & Avant, 1995). Adherence to a targeted weight loss is simply demonstrated by one measure: weight. Examples of secondary empirical referents would be normal hemoglobin A1c, blood pressure of ≤120/80, total cholesterol of <200, low-density lipoprotein cholesterol of <100, a decreased pain scale score in individuals with osteoarthritic-related joint pain, and high scores on QOL measurements. The relationships between the antecedents, critical attributes, and outcomes are shown in Figure 1.

Figure 1.

The Relationship Between the Antecendents, Critical Atributes, and Outcomes Associated with Maintaining Weight Loss

The following two cases provide examples of adherence and non-adherence in relation to weight management:

Model Case

Ms. A. is a 46-year-old woman who has lost weight several times in the past. Her first attempt was when she was 26 years old. Each time she was successful only to regain her weight within a year. She decided to try again, but this time she knew things were different. She felt more confident from what she had learned in the past. She was successful and happy in her job and was now working for a company that allowed her to take time off for health-promoting activities. She is dating someone who is overweight and also determined to lose weight. She also has more knowledge about the health benefits of weight loss and is seeing a nurse practitioner who has developed a multidisciplinary plan of care for her that includes frequent follow-up visits to monitor her weight loss. She has set realistic goals that include a low-fat, low-calorie diet, eating at least three regular meals a day, and daily exercise. She weighs herself every day and keeps a log of her progress. Her boyfriend participates in the same plan and whenever possible they eat and exercise together. After 6 months, she has lost 30 kg. She continues to watch her fat and calorie intake. She also continues to exercise and weighs herself daily. Five years later, she has continued to maintain her 30-kg weight loss with less effort. Her boyfriend, now husband, also maintains his weight loss. Despite family histories of diabetes and cardiac disease, they both have a normal blood pressure, normal blood sugar, and normal cholesterol and report a marked improvement in their quality of life.

Contrary Case

Ms. B. is a 21-year-old woman who tried to lose weight once before but was unsuccessful. She is 30 kg overweight and desperately wants to lose weight so she can look like the models in the magazines. She has decided to try again but is not very confident. Her job is very stressful and she works a lot of overtime hours and is given very little time off. Because she does not own a car and has to take public transportation to go to the grocery store, she finds herself frequently going to fast-food restaurants in her neighborhood because they are more accessible. She is dating someone who expresses that he likes women who have “meat on their bones” and he does little to encourage her. She only seeks medical care once a year for her gynecological exam or if she has an occasional respiratory infection. At these visits, a weight loss plan is never discussed. She decided if she stopped eating breakfast and lunch and ate only dinner she could lose weight. She also decided to go on a 2-week “cleansing” diet that prescribed eating only cabbage soup. She avoids weighing herself every day because she is afraid of being disappointed. She weighs herself once every few weeks. She lives in the city and rarely exercises because she does not feel safe to exercise in her neighborhood and she is not able to afford the cost of a health club membership. After 2 months, she lost 30 kg. She feels great; however, her boyfriend keeps telling her she is too skinny. She is tired of eating only one meal a day and has begun to slowly increase her intake to three meals a day. Three months later, she regained the 30 kg. She feels very discouraged and reports having a poor quality of life. At her annual gynecology appointment, she is found to have an elevated blood pressure, blood sugar, and cholesterol. She is not surprised about these findings because her whole family developed these health problems at an early age. She started treatment with a blood pressure medicine, an oral glycemic agent, and a cholesterol-lowering agent. Her medical visits have increased to every 3 months for blood pressure checks and blood glucose and cholesterol monitoring. After 5 years she remains obese. Her blood pressure, diabetes, and hyperlipidemia are in fair control after multiple changes in her medication regimens. She is thankful that her job has good health insurance with a prescription plan because her medications cost over $500 a month. She states that she is not dating anyone because her job and medical visits take up all of her free time.

Conclusion

The concept of adherence is complex. With only an estimated 21% of obese/overweight persons being successful at achieving long-term weight loss, clearly more research is needed in this area. Antecedents associated with adherence (self-efficacy, outcome expectation, perceived value, prior relapse, time, social support, knowledge, socioeconomic status, perception of harm or adverse effect, active participation, provider influence, mental status, motivation, and perceived goal attainability) are important to consider when conducting research and developing clinical strategies aimed at maintaining weight loss and long-term weight management.

Acknowledgment

The author would like to acknowledge Dr. Karen Elberson for her editorial assistance.

Ancillary