Obesity Surgery (2020) 30:4411–4421

https://doi.org/10.1007/s11695-020-04811-x

ORIGINAL CONTRIBUTIONS

Motivation and Weight Loss Expectations in Bariatric Surgery

Candidates: Association with 1- and 2-Year Results
After Bariatric Surgery
Caroline M. J. Theunissen 1 & Anne van Vlijmen 2 & Danny J. A. M. Tak 3 & Ivan Nyklíček 2 & Mariska A. C. de Jongh 1 &
Barbara S. Langenhoff 1

Received: 30 April 2019 / Revised: 21 June 2020 / Accepted: 22 June 2020 / Published online: 8 July 2020
# Springer Science+Business Media, LLC, part of Springer Nature 2020

Abstract
Purpose There are discrepancies between patients’ expected weight loss and what is considered achievable after bariatric
surgery. This study describes the association between patients’ expectations and actual weight loss, 1 and 2 years postoperatively.
Materials and Methods A prospective observational study was performed. The association between expectations and actual
weight loss (% total weight loss) was explored using linear regression analyses, adjusting for baseline demographics, surgery
types, and self-esteem (Rosenberg self-esteem scale) and repeated separately per gender. Gender differences in motivations were
explored using Chi-square tests.
Results Of 440 patients at baseline, results on 368 (84%) at 1 year and 341 (78%) patients at 2 years were available. Significant
and opposite associations were found when analyzing genders separately. There was a significant negative association between
expectations and %TWL in men at 1 year (β − 0.23, p = 0.04) and 2 years postoperatively (β − 0.26, p = 0.03), indicating smaller
weight loss for greater expectations. In women, a significant positive association (β 0.24, p < 0.01) was found 2 years postop-
eratively, indicating greater weight loss for greater expectations. Both genders were mainly motivated by health concerns, but
women were also motivated by reduced self-confidence to lose weight.
Conclusions Higher expectations were negatively associated with weight loss in men, but positively in women. This may be due
to men being motivated by physical complaints, which improve with lower weight-loss. Women are also driven by reduced self-
confidence, which may influence weight loss maintenance behaviors. Higher weight loss goals should not be considered as a
contra-indication for surgery, but may be utilized to achieve patients’ goals.

Keywords Bariatric surgery . Expectations . Motivations . Results . Weightloss . Gender differences . Roux-en-Y gastric bypass .
Sleeve gastrectomy

* Caroline M. J. Theunissen Barbara S. Langenhoff

c.m.j.theunissen@gmail.com b.langenhoff@etz.nl

Anne van Vlijmen 1

The Department of Surgery, Elisabeth-Tweesteden Hospital, Dr.
annevanvlijmen@gmail.com Deelenlaan 5, 5042 AD Tilburg, The Netherlands
Danny J. A. M. Tak
d.tak@etz.nl
2
The Department of Medical and Clinical Psychology, Tilburg
Ivan Nyklíček University, Tilburg, Netherlands
i.nyklicek@uvt.nl
3
Mariska A. C. de Jongh The Department of Clinical Psychology, Elisabeth-Tweesteden
m.dejongh@etz.nl Hospital, Tilburg, The Netherlands
4412
Introduction
Bariatric surgery candidates are screened by a multidisci-
plinary team for a wide array of factors, including their
expectations of the results of surgery [1–6]. Candidates
voice the hope for “normality” after surgery, expecting
improvements in their physical, mental, and social status
[7–9]. Weight loss expectations are high, with a “goal
weight” or “happy weight” that exceeds what literature
has shown to be realistic and with “disappointed weight”
reflecting what most professionals would consider a suc-
cess (> 50% excess weight loss or BMI < 35 kg/m 2 )
[10–19]. In a study by Bauchowitz et al., up to 65% of
patients over-estimated their weight loss (realistic goals
determined as 55–70% excess weight loss), and in a study
by Fischer et al., over 88% percent of patients set their
goals at > 50% excess weight loss [15, 18]. Higher “accept-
able” and “disappointing” weight loss goals have been var-
iably associated with patient attrition in non-surgical
weight loss treatments [20–22] and are attributed to disap-
pointment in the results of treatment. Attrition at post-
surgical follow-up has been associated with lower or un-
successful weight loss in bariatric surgery patients [23].
Although health concerns and improvement of comor-
bidities are often mentioned as important motivators for
surgery [10, 17, 18], patients often underestimate how
much their comorbidities can improve after surgery [17].
In a study by Wee et al., more patients (75.7%) were will-
ing to risk death to achieve their perceived ideal weight
than to achieve perfect health (53.4%) [11]. To achieve this
goal, patients considered a mortality risk of 6.7% accept-
able [8], which is much higher than the actual described
mortality (0.05% in the Netherlands [24]).
Patients’ postoperative expectations are routinely
assessed by mental health professionals during the preop-
erative evaluation process [4]. Up to 61.7% of health care
professionals involved in bariatric surgery consider unre-
alistic expectations a possible contra-indication for surgery
and some see it as a reason to delay or deny surgery [5, 6].
Clinicians will consequently aim to correct these unrealis-
tic expectations. However, while the relationship between
expectations and weight loss in non-surgical obesity treat-
ment has been more widely investigated—showing no or
even a slightly positive relationship between expectations
and weight loss in non-surgical treatments [25, 26]—only
two studies have documented the relationship between
these expectations and weight loss after bariatric surgery
[13, 27]. In the study by White et al., the Goals and
Relative Weights Questionnaire (GWRQ) [28] was used
to investigate the relationship between “dream”, “happy”,
“acceptable”, and “disappointed” weights and weight loss
results. They found that lower “acceptable” goal weights
OBES SURG (2020) 30:4411–4421
predicted higher actual weight loss at 12 months [13].
However, the description of goal weights according to
these categories may define a patient’s “hopes” rather than
the goal they strive for. In the study by Aelfers et al., pa-
tients were divided into groups, depending on whether pa-
tients’ estimation of weight loss was correct (60–70% ex-
cess weight loss for gastric bypass and gastric sleeve),
overestimated, or underestimated. Gastric bypass patients
who overestimated their weight loss had a significantly
greater weight loss at 12 months, and overestimating goals
was significantly and positively linked to reaching > 50%
excess weight loss [27]. However, patients were given ex-
tensive instructions on how to calculate their estimated
weight loss, which therefore may no longer completely
reflect their expectations. It was also unclear in both stud-
ies whether baseline characteristics and weight had been
adjusted for in the analyses.
Gender-based differences in expectations and motiva-
tions have been previously studied with varying results.
No differences between genders in terms of weight loss
expectations were found in studies by Bauchowitz et al.
and Fischer et al. [15, 18]. However, Kaly et al. and
Heinberg et al. found women to expect greater weight
losses than men [12, 16]. Motivation to undergo surgery
(i.e., health concerns, body shape concerns) may also differ
[29]. Self-esteem (subjective evaluation of a person’s own
worth and competencies) at baseline has been shown to
correlate positively with goal weights for bariatric surgery
patient groups, i.e., patients with higher self-esteem aimed
for lower weight loss [20, 28].
On the one hand, higher weight loss expectations may be
due to patients believing more weight loss is necessary to
achieve the desired improvement in health and they are will-
ing to accept high risks to achieve it. On the other hand, dis-
appointed weight loss expectations may result in attrition from
post-surgical follow-up and negatively impact results.
However, if weight loss goals are not negatively associated
with weight loss results, clinicians might focus on setting re-
alistic expectations in terms of the psychological and social
impact of the surgery rather than weight loss. This may im-
prove weight loss maintenance behavior after surgery [30].
This study aimed to explore patients’ motivations for sur-
gery and factors associated with patients’ expectations of
weight loss after bariatric surgery. Furthermore, this study
aimed to investigate more precisely the association between
weight loss expectations and weight loss results, when taking
baseline characteristics, differences between genders, and
baseline self-esteem into account. Based on the trend towards
a positive association in previous research in non-surgical and
surgical groups [13, 25–27], it was hypothesized that a posi-
tive association (indicating greater weight loss for higher ex-
pectations) would be found.
OBES SURG (2020) 30:4411–4421
Materials and Methods
Participant Selection
A prospective observational study was conducted. Both clin-
ical and psychological factors were investigated at baseline
and 1 and 2 years postoperatively. Following national multi-
disciplinary guidelines [4], patients between 18 and 65 years
old with a BMI of ≥ 40 kg/m2 or ≥ 35 kg/m2 with obesity-
associated comorbidity were eligible for screening by a mul-
tidisciplinary team.
After screening, patients were directly approved or rejected
for surgery, or delayed and assigned to pre-operative addition-
al counseling. Pre-operative additional counseling was per-
formed by a dietician, psychologist, or both. After successful
completion of counseling, patients were approved for surgery.
Patients with active and severe psychopathology according
to the DSM-5 were referred to national mental healthcare pro-
viders for treatment before surgery was considered.
Psychopathology such as mild eating disorders were treated
in the presurgical course by the multidisciplinary team, as
advised in the Dutch national monodisciplinary bariatric psy-
chology guidelines [31].
All patients screened for bariatric surgery in the Obesity
Centre of the Elisabeth-TweeSteden Hospital between
January 2011 and May 2015 completed a standardized
Dutch screening form inquiring about their health, social
status, their obesity-related problems, and their motivation
for surgery and weight loss. All patients also received in-
formation on this study, requesting them to fill in several
standardized psychological questionnaires online at the
time of screening and 1 and 2 years postoperatively.
When informed consent was obtained, patients were sent
an email with a personalized link to the questionnaires.
Patients were informed that the screening team would not
have access to the results of the online questionnaires and
asked to complete them before they were informed of the
team’s decision (generally 1–2 weeks after screening).
This way, the chance of patients aiming for socially desir-
able answers, or their answers being influenced by accep-
tance or rejection for surgery was minimized. Up to 2 years
postoperatively, patients received a new email link to the
questionnaires after their annual clinical follow-up.
Weight Loss Measures
Weight at baseline was expressed as body mass index (BMI),
calculated as weight in kilograms, divided by the square of the
patient’s height in meters as measured at the screening. The
current weight status was measured at the annual clinical fol-
low-up. For the follow-up, the percentage of total weight loss
(%TWL) is reported [32, 33].
4413
The standardized screening form included the questions
“How much do you think you will weigh after the surgery?”
answered in kilogram and “In what amount of time do you
think you will achieve this weight?” answered in weeks. The
expected total weight loss (exp%TWL) was calculated based
on the weight patients reported here.
Psychological Questionnaire
The Dutch translation of the Rosenberg Self-esteem Scale
(RSES) [34] was used. The RSES is a 10-item self-reported
questionnaire, which measures global self-esteem. Items are
scored from 0 (strongly agree) to 3 (strongly disagree), with
higher scores indicating higher self-esteem.
Patients’ Motivations
The standardized screening form also included the question
“What is/are the most important reason(s) you wish to lose
weight?”. Patients could choose multiple answers out of the
following options: prevention of physical problems in the future,
current health-related problems, lack of energy and stamina,
problems in daily functioning and self-care, desire to reduce
medication, sexual problems, remarks from others/social prob-
lems, reduced self-esteem/confidence, shame over physical ap-
pearance, problems buying clothes that fit, and other problems.
Statistical Analyses
All data were analyzed using IBM SPSS Statistics©, version
24. The demographic characteristics of the patient groups
were explored and comparisons between men and women
were made by performing Chi-square tests and independent t
tests per variable. All continuous variables were normally dis-
tributed by approximation with skew not exceeding ± 1.1 and
kurtosis not exceeding ± 2.3.
To explore any correlations between expectations and the
various continuous predicting variables and outcome mea-
sures, a Pearson bivariate correlation analysis was performed.
To explore any differences in weight loss expectations and
actual weight loss between genders, working status, and edu-
cation levels, independent t tests were performed. Differences
in expectations and actual weight loss per motivator for sur-
gery were investigated using independent sample t tests. Due
to the multiple-answers possible for the motivations for sur-
gery, Bonferroni corrections (α = 0.05/11 = 0.0045) for mul-
tiple testing were applied for these analyses. For all other
analyses, a p value of ≤ 0.05 was considered significant.
A linear multiple regression analysis was performed to ex-
amine the association between weight loss expectations and
weight loss at 1 and 2 years postoperatively, using %TWL to
express weight loss and weight loss expectations. To test for
4414 OBES SURG (2020) 30:4411–4421

confounding, variables were entered into the model one by
one. In the final model, all confounders were included that
changed the regression coefficient (Bèta) for %TWL by
10% or more [35] at either time point (1 or 2 years), indepen-
dent of significance. The final model contained the following
variables: patient characteristics (age, gender, and baseline
BMI), socioeconomic status (employment status, level of ed-
ucation), treatment-specific factors (the type of surgery and
the requirement of preoperative counseling), and self-esteem
(total RSES score).
Because of the differences in expectations and motivations
between men and women, separate linear multiple regression
analyses were performed for men and women. Due to the
difference in group size between men and women, post hoc
power analyses for linear regression (nQuery 8 ©, Statsols)
were performed for both gender groups at both time points.
Based on the explained variance of the linear regression model
at 1 year (R2 0.193) and 2 years (R2 0.288), required sample
sizes of, respectively, 75 and 48 male patients were estimated
to achieve 80% power. For women, the estimated required
sample size was, respectively, 153 (based on R2 0.098) at
1 year and 117 (based on R2 0.127) at 2 years. The sample
sizes exceeded these numbers and the linear regressions were
considered to have sufficient power. To explore any associa-
tion between expectations and weight regain, logistic regres-
sion was performed using the same variables and sustained
weight loss as an outcome (indicating equal or increased
weight loss at 2 years compared to 1 year postoperatively).
Results
Participants’ Sociodemographic Characteristics
A total of 1951 patients were screened between January
2011 and May 2015: 1347 patients (69%) either refused
participation or did not complete the psychometric ques-
tionnaires after initial inclusion (n = 180). The 604 partic-
ipating patients did not differ in gender (p = 0.41) or BMI
(p = 0.90) from those who did not participate, but differed
in age (mean age of participants 44.4 years (SD 10.9)
versus 41.6 (SD 11.2) years, p < 0.001).
Out of 604 participants, 479 received bariatric surgery after
screening and completion of counseling. Only patients under-
going laparoscopic Roux-en-Y gastric bypass (LRYGB, n =
419) or laparoscopic sleeve gastrectomy (LSG, n = 21) were
included for further multiple regression analysis, excluding
patients who underwent primary adjustable gastric banding
(n = 3) or revision of gastric band or gastric sleeve to gastric
bypass (n = 36) (Table 1). The analyzed group did not differ
significantly from the excluded and non-operated patients on
age (p = 0.88) or gender (p = 0.49), but they had a higher

Table 1 Baseline characteristics

operated patients N = 440 Mean (SD)

Age (years) 44.4 (10.5)

BMI (kg/m2) 43.3 (5.3)
n = (%)
Gender Male 100 (22.7%)
Female 340 (77.3%)
a
Education level Low (no schooling, primary education, 142 (32.3%)
pre-vocational secondary education)
Average (secondary education, vocational education) 232 (52.7%)
Higher (higher professional education/university/postdoc) 63 (14.3%)
Working statusb Unemployed/ disability leave 79 (18.0%)
Employed/ volunteer work 328 (74.5%)
Retirement/home-maker/other 31 (7.0%)
Screening results Direct approval for surgery 209 (47.5%)
Dietary counseling 85 (19.3%)
Psychological counseling 82 (18.6%)
Dietary and psychological counseling 56 (12.7%)
Referral to national mental healthcare 8 (1.8%)
Type of surgery LRYGB 419 (95.2%)
LSG 21 (4.8%)
a
Data on three patients unknown
b
Data on two patients unknown
LRYGB Roux-en-Y gastric bypass, LSG sleeve gastrectomy
OBES SURG (2020) 30:4411–4421 4415

baseline BMI (mean 43.3 (SD 5.3) vs. 42.2 (SD 5.8) kg/m2,
p = 0.03). This may be explained by a lower BMI in patients
who have already undergone previous surgery and patients
not qualifying for surgery based on their weight. RYGB and
LSG patients did not differ significantly on baseline (p = 0.74)
or follow-up BMI (1 year p = 0.19; 2 years p = 0.29) and were
therefore analyzed as a single group.
The majority of patients in the analyzed group (Table 1)
were female (78.5%), with a mean age of 44.3 years (SD
10.3) and a mean BMI of 43.2 (SD 5.5) kg/m2. The major-
ity had achieved an average level of education (53.0%,
completed secondary education/vocational education) or
higher (14.4%, higher professional education/university/
postdoc) and were employed (75.0%). During screening,
209 patients (47.5%) were directly approved for surgery
after screening, and the remaining 231 (52.5%) referred
to the dietician, psychologist, or mental health care service
for additional counseling before surgery.
Complete follow-up data were available for 368 (83.6%)
patients at 1-year and 341 (77.5%) patients at 2 years
postoperatively.
Motivation and Expectations
Ongoing physical complaints were reported most often as
motivation for surgery (85.9%), followed by lack of energy
(82.7%), prevention of physical complaints (75.5%), and
problems in daily functioning and self-care (72.0%)
(Table 2). These were also the main motivators within gender
groups. When comparing genders, men reported current phys-
ical complaints as motivation (96.0% vs. 82.9%, p = 0.001)
more often than women. Women significantly more often re-
ported a reduction in self-confidence (63.2% vs. 41.0%,
p < 0.001) as a motivation for bariatric surgery.
Out of 440 patients, 30 did not indicate their expected
weight loss. On average, patients expected to achieve 34.8%
TWL (SD 6.3). Women expected to lose more weight than
men (35.2% versus 33.6% TWL, p = 0.02). However, men
expected to reach the expected weight within a significantly
shorter period than women: 45.6 weeks (SD 17.0) versus
51.3 weeks (SD 19.0) (p = 0.02).
When exploring weight loss expectations per motivating
factor, patients who stated ongoing physical complaints as a
motivation expected less weight loss. Patients motivated by
the prevention of physical complaints, lack of energy, and
problems buying clothing expected to lose more weight.
Actual weight loss at 1 year was greater for patients who were
motivated by the prevention of physical complaints or prob-
lems in daily functioning. At 2 years postoperatively, patients
stating prevention of physical complaints, lack of energy, and
social/remarks from others as motivations achieved greater
mean weight loss. However, when Bonferroni correction for

Table 2 Comparison per gender

in motivations, expectations, and Men Women Total group Statisticsa
self-esteem Motivation n = 100 n = 340 N = 475 p=

Prevention of physical complaints 73 (73.0%) 259 (76.2%) 332 (75.5%)c 0.52

Ongoing physical complaints 96 (96.0%) 282 (82.9%) 378 (85.9%) 0.001c
Lack of energy 83 (83.0%) 281 (82.6%) 364 (82.7%) 0.94
Problems in daily functioning 71 (71.0%) 246 (72.4%) 317 (72.0%) 0.79
Desire to reduce medication 39 (39.0%) 95 (27.9%) 134 (30.5%) 0.04
Sexual complaints 30 (30.0%) 71 (20.9%) 101 (23.0%) 0.06
Social/remarks from others 34 (34.0%) 103 (30.0%) 137 (31.1%) 0.48
Reduced self-confidence 41 (41.0%) 215 (63.2%) 256 (58.2%) < 0.001c
Shame over appearance 51 (51.0%) 211 (62.1%) 262 (59.5%) 0.05
Problems buying clothes 67 (67.0%) 194 (57.1%) 261 (59.3%) 0.08
Other motivation 7 (7.0%) 46 (13.5%) 53 (12.0%) 0.08

Expectations weight lossb n = 94 n = 316 N = 410 p=

Expected %TWL 33.6 (6.5) 35.2 (6.2) 34.8 (6.3) 0.02
Time (weeks) to expected weight loss 45.6 (17.0) 51.3 (19.0) 50.0 (18.7) 0.02

Self-esteemb n = 100 n = 340 N = 440 p=

RSES total score 21.2 (5.4) 19.8 (5.7) 20.1 (5.6) 0.04
a
Chi-square test or independent t testing to compare genders
b
Mean and standard deviation (SD) given unless otherwise specified
c
Meets significance threshold when Bonferroni correction is applied (α = 0.0045)
BMI body mass index, %TWL % total weight loss, RSES Rosenberg Self-esteem Scale
4416
multiple testing was applied (α < 0.0045), none of these dif-
ferences remained significant.
When repeating these analyses within gender groups,
women motivated by problems buying clothes expected to
lose more weight. However, women motivated by ongoing
physical complaints expected to lose less weight. Men moti-
vated by prevention of physical complaints and problems buy-
ing clothes expected to lose more weight than men who did
not. Actual weight loss at 1 year was greater for women mo-
tivated by the prevention of physical complaints or problems
buying clothes and for men motivated by problems in daily
functioning. At 2 years postoperatively, %TWL was greater
for women motivated by prevention of physical complaints,
reduced energy, or social/remarks from others. No differences
in weight loss at 2 years were found per motivation for men.
However, when Bonferroni correction for multiple testing was
applied (α < 0.0045) to these gender group analyses, none of
these differences remained significant.
Psychological Variables
The mean score on self-esteem was 20.1 (SD 5.6) for the total
group, which is comparable to the Dutch norm sample (mean
20.9, SD 4.4) [34]. Women scored significantly lower (mean
19.8, SD 5.7) than men (mean 21.2, SD 5.4) (t 2.1, df 473,
p < 0.05), which is also consistent with literature.
Weight Loss at 1 Year and 2 Years Postoperatively
Patients’ weight decreased from a mean BMI of 43.3 kg/m2
(SD 5.3) to a BMI of 29.5 kg/m2 (SD 4.2) at 1 year, which
remained 29.4 kg/m2 (SD 4.3) at 2 years postoperatively. This
corresponds to 31.8% and 31.9% TWL at 1 and 2 years post-
operatively. Men and women differed significantly at baseline
weight (mean BMI 42.1 (SD 4.4) versus 43.7 (SD 5.5) kg/m2,
p < 0.01) and in terms of %TWL at 1 year (29.7% versus
32.5%, p = 0.001) and 2 years (29.0% versus 32.7%,
p < 0.001) (Table 3).
Table 3 Actual weight-loss
BMI kg/m2 Total group
Men
Women
%TWL Total group
Men
Women
Mean and standard deviation (SD) given
Independent t testing applied to compare genders. Significant at *p < 0.01 and **p ≤ 0.001 level
BMI body mass index, %TWL % total weight loss
OBES SURG (2020) 30:4411–4421
Exploring Weight Loss Expectations per Predictor
Correlations between weight loss expectations and actual
weight loss were explored. Expectations had a small but sig-
nificant positive correlation with %TWL at 1 and 2 years
(Table 4). Age was negatively correlated with expected
%TWL and %TWL at 1 and 2 years, indicating that older
patients had slightly lower weight loss expectations and actual
weight loss. Patients with a low level of education had signif-
icantly lower expectations and weight loss than those with an
average to higher level of education. No differences in expec-
tations or weight loss were found across categories of working
status or need for preoperative counseling.
Association Between Expectations and Actual Weight
Loss at 1 and 2 Years
The linear multiple regression to analyze the association be-
tween weight loss expectations and actual weight loss for the
total group—adjusting for demographics, treatment, and self-
esteem at each level—showed no significant association be-
tween expectations and %TWL at 1 year and 2 years after
surgery, adjusting for demographics, treatment, and self-
esteem at each level. In the final model, baseline BMI, age,
gender, and type of surgery were significantly associated with
weight loss at 1 year after surgery (Table 5), while at 2 years
after surgery, the association between age and weight loss lost
its significance (Table 6).
In the separate analysis of the association between expec-
tations and weight loss per gender, there was a significant
negative association with %TWL (β − 0.23, 95% CI − 0.45–
− 0.01, p = 0.04) for men at 1 year after surgery, indicating
smaller weight loss where greater weight loss expectations
were reported. This association was not significant for women
at 1 year after surgery. In the final linear models, baseline BMI
and self-esteem had a significant positive association with
weight loss for men but were not significantly associated with
weight loss for women. Age and sleeve gastrectomy had a
Baseline 1 year 2 years
N = 440 (340 women) N = 368 (279 women) N = 341 (265 women)
43.3 (5.3) 29.5 (4.2) 29.4 (4.3)
42.1 (4.4)* 29.5 (3.4) 29.9 (3.4)
43.7 (5.5)* 29.5 (4.4) 29.3 (4.5)
31.8 (6.8) 31.9 (7.8)
29.7 (6.0)** 29.0 (6.7)**
32.5 (7.0)** 32.7 (7.9)**
OBES SURG (2020) 30:4411–4421 4417

Table 4 Exploring correlations with weight loss expectations

Expected %TWL % TWL 1 year % TWL 2 years

Bivariate correlation Pearson’s r (significance p)

BMI baseline 0.36 (p < 0.001) 0.11 (p = 0.002) 0.16 (p < 0.001)
Expected %TWL 0.10 (p = 0.007) 0.14 (p < 0.001)
Age − 0.09 (p = 0.005) − 0.13 (p < 0.001) − 0.11 (p = 0.003)
Self-esteem (RSES) − 0.04 (p = 0.36) 0.03 (p = 0.41) 0.05 (p = 0.23)
Education levela
Low 33.9 (6.0) (p = 0.04) 30.7 (6.0) (p = 0.04) 30.5 (6.8) (p = 0.03)
Average to high 35.3 (6.4) 32.3 (7.2) 32.4 (8.1)
Working statusa
Unemployed/disability leave 35.0 (6.4) (p = 0.90) 31.4 (7.4) (p = 0.63) 30.7 (8.4) (p = 0.25)
Employed/retired/home-maker 34.8 (6.3) 31.9 (6.8) 32.1 (7.6)
Preoperative counselinga
Dietician/psychologist/both 35.3 (6.2) (p = 0.10) 32.4 (6.3) (p = 0.12) 32.4 (7.0) (p = 0.21)
Direct surgery approval 34.3 (6.4) 31.2 (7.4) 31.3 (8.5)

BMI body mass index, %TWL % total weight loss, RSES Rosenberg Self-esteem Scale
a
Mean and standard deviation given (SD), independent t test performed

significant negative association with weight loss in women
but were not significant in men (Table 5).
At 2 years postoperatively, weight loss expectations
were significantly and negatively associated with %TWL
in men (β− 0.26, 95% CI − 0.50–− 0.02, p = 0.03), but
positively associated with actual weight loss in women
(β 0.24, 95% CI 0.06–0.42, p < 0.01). This indicates
that greater weight loss expectations were associated
with less weight loss in men, but more weight loss in
women (Table 6).

Table 5 Linear regression for association between expectations and %TWL 1 year postoperatively

Men Women Total group

B 95% CI p B 95% CI p B 95% CI p

Expected %TWL, unadjusted − 0.07 − 0.26–0.12 0.45 0.21 0.07–0.34 < 0.01 0.15 22.6–30.7 0.01
Expected %TWL, adjusted for demographicsa − 0.27 − 0.49–− 0.05 0.02 0.12 − 0.04–0.28 0.14 0.03 − 0.10–0.16 0.65
Expected %TWL, adjusted for socioeconomic statusb − 0.27 − 0.50–− 0.05 0.02 0.11 − 0.05–0.28 0.17 0.02 − 0.11–0.16 0.73
Expected %TWL, adjusted for treatmentc − 0.27 − 0.50–− 0.04 0.02 0.11 − 0.05–0.27 0.18 0.03 − 0.10–0.16 0.67
Regression coefficients of individual variables in final model
Expected %TWL − 0.23 − 0.45–− 0.01 0.04 0.11 − 0.05–0.27 0.18 0.03 − 0.10–0.16 0.67
BMI 0.55 0.17–0.93 < 0.01 0.09 − 0.10–0.28 0.36 0.16 − 0.002–0.33 0.06
Age 0.06 − 0.09–0.21 0.42 − 0.09 − 0.18–− 0.002 0.05 − 0.08 − 0.16–− 0.02 0.04
Female gender 2.25 0.68–4.06 0.01
Unemployed 0.45 − 3.11–4.01 0.80 0.12 − 2.32–2.56 0.92 − 0.06 − 2.10–1.97 0.95
Average or high education − 0.31 − 2.80–2.18 0.81 1.14 − 0.86–3.14 0.26 0.71 − 0.89–2.32 0.38
Required pre-op counseling 0.35 − 2.20–2.90 0.79 1.32 − 0.41–3.05 0.13 1.16 − 0.30–2.62 0.12
Surgery type: gastric sleeve 1.19 − 3.59–5.98 0.62 − 5.62 − 9.46–− 1.78 < 0.01 − 3.27 − 6.36–0.18 0.04
Self-esteem 0.34 0.08–0.59 0.01 0.06 − 0.09–0.22 0.42 0.12 − 0.02–0.25 0.08

Outcome = %TWL (% total weigh loss)

a
Adjusted for demographics: age, BMI, gender (for total group)
b
Adjusted for socioeconomic status: employment and education level
c
Adjusted for treatment: gastric sleeve, preoperative counseling
4418 OBES SURG (2020) 30:4411–4421

Table 6 Linear regression for association between expectations and %TWL 2 years postoperatively

Men Women Total group

B 95% CI p B 95% CI p B 95% CI p

Expected %TWL, unadjusted − 0.02 − 0.24–0.19 0.83 0.32 0.17–0.48 < 0.001 0.25 0.12–0.38 < 0.001
Expected %TWL, adjusted for demographics a
− 0.30 − 0.54–− 0.07 0.01 0.25 0.07–0.42 < 0.01 0.13 − 0.02–0.27 0.09
Expected %TWL, adjusted for socioeconomic − 0.30 − 0.54–− 0.06 0.02 0.24 0.06–0.42 0.01 0.12 − 0.03–0.27 0.11
statusb
Expected %TWL, adjusted for treatmentc − 0.30 − 0.54–− 0.05 0.02 0.24 0.06–0.42 < 0.01 0.12 − 0.03–0.27 0.11
Regression coefficients of individual variables in final model
Expected %TWL − 0.26 − 0.50–− 0.02 0.03 0.24 0.06–0.42 < 0.01 0.13 − 0.02–0.27 0.09
BMI 0.85 0.42–1.27 < 0.001 0.11 − 0.11–0.32 0.32 0.22 0.03–0.41 0.03
Age 0.18 0.01–0.35 0.04 − 0.07 − 0.17–0.03 0.17 − 0.05 − 0.14–0.04 0.26
Female gender 3.05 1.04–5.07 < 0.01
Unemployed − 1.01 − 5.18–3.17 0.63 − 0.83 − 3.57–1.91 0.55 − 1.25 − 3.57–1.07 0.29
Average or high education − 0.31 − 3.24–2.62 0.83 0.60 − 1.65–2.85 0.60 0.40 − 1.45–2.24 0.67
Required pre-op counseling 1.57 − 1.42–4.55 0.30 1.12 − 0.83–3.06 0.26 1.20 − 0.48–2.87 0.16
Surgery type: gastric sleeve 0.74 − 4.88–6.37 0.79 − 6.80 − 11.58–− 2.01 < 0.01 − 3.80 − 7.63–0.04 0.05
Self-esteem 0.32 0.03–0.61 0.03 0.12 − 0.06–0.30 0.19 0.15 − 0.003–0.31 0.06

Outcome = %TWL (% total weigh loss)

a
Adjusted for demographics: age, BMI, gender (for total group)
b
Adjusted for socioeconomic status: employment and education
c
Adjusted for treatment: gastric sleeve, preoperative counseling

A logistic regression analysis was performed to explore the
association between expectations and sustained weight loss
postoperatively (Table 7). Out of 313 patients measured at 1
and 2 years postoperatively, 151 maintained or improved their
weight loss at 2 years when compared to 1 year post-opera-
tively. Only in men, age was significantly associated (OR
0.91, 95% CI 0.84–0.98, p < 0.01) with sustained weight loss,
indicating that increasing age is associated with a lower
chance of maintaining or improving weight loss after 1 year.
No significantly associated variables were found in women or
the total group. Weight loss expectations were not significant-
ly associated with sustained weight loss for either gender or
the total group, nor were any of the other variables.
Discussion
Expectations were not significantly associated with weight
loss at 1 or 2 years after bariatric surgery for the total study
group. However, when separate analyses per gender were
performed, a significant association was found between
weight loss expectations and weight loss for men at 1 year
and for both genders at 2 years postoperatively. Higher
expectations in women were associated with greater weight
loss, but the opposite was true for men. This might reflect
the possibility that since women are more often driven by
reduced self-confidence as well as by their health, they
strive to achieve and maintain their greater weight loss
goals. Men seem to be more often driven solely by health
factors. The smaller amount of weight loss generally nec-
essary to achieve improvements in comorbidities might
stop them from striving for further weight loss once their
goals have been achieved. The findings that men and wom-
en differ in their motivations for surgery, but that overall
health concerns are the most important motivations, are in
line with the literature [14, 17, 18, 29]. Women expected to
lose significantly more weight than men, which is also
consistent with the literature [12].
Higher weight loss expectations might decrease postoper-
ative satisfaction, weight loss, mood and weight maintenance
behaviors, and thereby cause higher attrition [20, 21, 28, 36],
but other studies argue that higher expectations might also
positively influence weight maintenance behaviors [36].
Weight loss expectations have been described to have either
no effect or a positive effect on weight loss after bariatric
surgery [13, 27]. Some of the differences in results might be
explained by the different definitions of “expectations”. Many
articles use the GWRQ or ask what a patient hopes to weigh
after the weight loss intervention. This may reflect the pa-
tient’s wishful thinking rather than their actual expectations
[26]. In this study, patients were asked what their expected
weight was before they received any official counseling on the
weight loss that may be achievable with bariatric surgery, to
reduce any bias.
OBES SURG (2020) 30:4411–4421 4419

Table 7 Logistic regression for association between expectations and sustained weight-loss between 1 and 2 years

Men Women Total group

B OR 95% CI p B OR 95% CI p B OR 95% CI p

Expected TWL, unadjusted − 0.01 0.99 0.93–1.06 0.83 1.17 0.96 0.92–1.00 0.08 − 0.03 0.97 0.93–1.00 0.07
Expected TWL, adjusted for demographics 0.04a
1.04 0.95–1.13 0.41 − 0.02 0.98 0.93–1.03 0.43 − 0.01 0.99 0.94–1.03 0.52
Expected %TWL, adjusted 0.04 1.04 0.96–1.14 0.35 − 0.02 0.98 0.93–1.03 0.43 − 0.01 0.99 0.95–1.03 0.53
for socioeconomic statusb
Expected TWL, adjusted for treatmentc 0.04 1.04 0.96–1.14 0.35 − 0.02 0.98 0.93–1.03 0.42 − 0.01 0.99 0.95–1.03 0.53
Regression coefficients of individual variables in final model
Expected TWL 0.04 1.04 0.96–0.14 0.34 − 0.02 0.98 − 0.93–1.03 0.42 − 0.01 0.99 0.95–1.03 0.52
BMI − 0.16 0.85 0.72–1.00 0.06 − 0.03 0.97 0.91–1.03 0.31 − 0.04 0.96 0.90–1.02 0.14
Age − 0.10 0.91 0.84–0.98 < 0.01 0.01 1.01 0.98–1.04 0.44 − 0.01 1.00 0.97–1.02 0.72
Female gender − 0.49 0.62 0.35–1.08 0.09
Unemployed 0.34 1.40 0.30–6.47 0.66 − 0.22 0.80 0.36–1.80 0.59 − 0.03 0.98 0.49–1.93 0.94
Average or high education 0.57 1.77 0.60–5.26 0.30 − 0.19 0.83 0.43–1.59 0.57 − 0.08 0.93 0.54–1.58 0.78
Required pre-op counseling − 0.25 0.78 0.26–2.33 0.65 0.04 1.04 0.60–1.81 0.89 − 0.01 1.00 0.61–1.61 0.98
Surgery type: gastric sleeve 0.64 1.91 0.24–14.95 0.54 0.17 1.19 0.32–4.35 0.80 0.14 1.15 0.40–3.35 0.79
Self-esteem 0.01 1.01 0.91–1.13 0.81 − 0.02 0.98 0.93–1.03 0.45 − 0.01 0.99 0.95–1.04 0.80

Outcome = sustained or greater weight-loss between 1 and 2 years postoperatively

a
Adjusted for demographics: age, BMI, gender (for total group)
b
Adjusted for socioeconomic status: employment and education
c
Adjusted for treatment: gastric sleeve, preoperative counseling

In line with previous research [12, 16], a negative correla-
tion between age and weight loss expectations was found for
all participants and for women in particular, indicating that
younger female patients have greater weight loss expectations.
Greater weight loss expectations in younger people may re-
flect differences in general knowledge about surgery, different
motivations, or a different psycho(patho)logical profile and
requires further research.
Contrary to findings in previous research, self-esteem did
not correlate significantly to expectations, but was positively
associated with 1 and 2-year weight loss in men. While wom-
en had lower baseline self-esteem compared to men, self-
esteem was not associated with weight loss results in women.
However, as a limitation of this study, it should be noted that
RSES is a very general measure of self-esteem and may not
reflect weight-specific self-esteem.
Low percentages of participation and a high loss to follow-
up are common problems in bariatric surgery research [37].
This may result in patient bias: more highly motivated patients
participating and patients with less successful results leaving
studies. A large percentage of patients screened at our center
did not want to participate in the study, with participating
patients being significantly older than non-participating pa-
tients. This limits the generalizability of the present results.
The results of bariatric surgery are not merely defined as
weight loss, but also by the improvement in quality of life and
comorbidities. A 5–10% weight reduction is associated with a
significant improvement in comorbidities such as hyperten-
sion, hypercholesterolemia, and hyperglycemia [38, 39]. The
perceived improvement in these comorbidities may influence
the patient’s determination to lose more weight and should
therefore also be explored as a possible predictor of weight
loss results in the long term. Individual motivations to achieve
weight loss should be one of the topics discussed during pre-
operative counseling, keeping possible gender differences in
mind. This study explored the association between weight loss
expectations and weight loss results as continuous measures,
showing opposite results for men and women. Future studies
may explore how realistic these expectations are, as well as the
implications for weight loss results after bariatric surgery.
Conclusion
Gender groups differ on baseline both in motivation for bar-
iatric surgery and weight loss expectations. Greater weight
loss expectations—when adjusted for demographics, socio-
economic status, treatment, and self-esteem—were associated
with greater weight loss in women and smaller weight loss in
men in this study. This may be partly explained by women not
only being driven by health concerns, but also by reduced self-
confidence, causing them to strive for greater weight loss.
Men were more often driven by health concerns, which may
cause them to stop striving for further weight reduction once
4420
their health has improved. Further studies are needed to deter-
mine if achieved health-goals explain why expectations are
negatively related to weight loss in men.
Acknowledgements We would like to thank Monique de Kort, specialist
nurse for bariatric surgery, for her diligent work in the follow-up of our
patient group.
Funding Information The department of surgery was funded for this
research by the VGZ Healthcare Insurance Innovation Fund (P6500/
D3957) and CZ Healthcare Insurance Fund (201500203), the
Netherlands. The authors declare that they have no other conflicts of
interest.
Compliance with Ethical Standards
Conflict of Interest This study was funded by the VGZ Healthcare
Insurance Innovation Fund (P6500/D3957) and CZ Healthcare
Insurance Fund (201500203), the Netherlands. The authors declare that
they have no other conflicts of interest.
Ethical Approval All procedures performed in this study were in accor-
dance with the ethical standards of the institutional and national research
committee and with the 1964 Helsinki Declaration and its later amend-
ments or comparable ethical standards. Informed consent was obtained
from all individual participants included in the study.
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