Overweight, Weight Loss, and Self-Reported Global Life Satisfaction: The Lolland-Falster Health Study

The prevalence of overweight (body mass index [BMI] ≥25) is increasing worldwide [1]. In addition to health-related risks and functional challenges of being overweight, overweight has also been associated with reduced life satisfaction and quality of life (QoL) [2, 3].

The terms quality of life and life satisfaction are used interchangeably in the literature [4]. WHO defines quality of life as “an individual’s perception of their position in life in the context of the culture and value systems in which they live and in relation to their goals, expectations, standards and concerns” [5]. Life satisfaction has been defined by several psychologists and sociologist, but one generally accepted definition, by sociologist Ruut Veenhoven, is that “Life satisfaction is the degree to which a person positively evaluates the overall quality of his/her life as a whole. In other words, how much the person likes the life he/she lead” [6].

In medical obesity studies, QoL is often used and can be assessed using several different measures, e.g., global QoL, health-related QoL (HRQoL), and obesity-specific QoL. Kolotkin and Andersen [7] found that obesity (BMI ≥30) was associated with lower generic and obesity-specific HRQoL. Mendes and Naliato [8] found a dose-response association between BMI and HRQoL where a high BMI was correlated to a low HRQoL, especially impacting the functional aspects.

The lower QoL may be related to weight stigmatization and discrimination challenging the mental health [9, 10]. A recent systematic literature review of randomized trials with long follow-up found no evidence to support that weight loss interventions resulted in a reduction of cardiovascular events [11]. Therefore, satisfaction with life has become an increasingly important parameter for motivating individuals to lose weight [11].

Quantifying QoL is often based on either generic or obesity-specific assessments. Some questions in these questionnaires are suitable for assessment of functional challenges rather than QoL or satisfaction with life, e.g., “because of my weight, I have trouble tying my shoes” (the Impact of Weight on Quality of Life) [12]. A major reduction in weight will likely improve the score but might not truly improve the actual life satisfaction. Assessment of global life satisfaction is relevant in clinical practice as it seems to be a health indicator, which may predict both psychiatric and somatic morbidity and all-cause mortality [13, 14]. Assessment of the global satisfaction with life can be done using several different measures, e.g., the Cantril Ladder, an 11-point scale (from 0 to 10) measuring subjective global well-being and general satisfaction with life, used by Gallup to make the “Life Evaluation Index” in the “World Poll” and to make the “World Happiness Report” [15].

In the Western world and its medical practice, it is a prevailing assumption that being an individual with BMI ≥25 is related to having a lower life satisfaction than people with a “normal” BMI (18.5–24.9 kg/m²), and that a weight loss will result in increased life satisfaction [16, 17]. The aim of this study was to investigate if overweight is associated with lower self-reported global life satisfaction as assessed by CLS compared with normal-weight individuals and to investigate if a history of weight loss among individuals with overweight was associated with higher life satisfaction compared with weight-stable individuals with overweight.

The present study was conducted with data from the Lolland-Falster Health Study (LOFUS). Our study used observational cross-sectional data including the participants’ history of weight change for a retrospective longitudinal analysis. LOFUS is a prospective household-based population study targeting the mixed rural-provincial population of 103,000 on the Danish islands, Lolland and Falster. It is a disadvantaged area, where income and educational level are lower and life expectancy is shorter than average in the Danish population [18]. Also, disease burden is higher in Lolland-Falster, which makes it different from previously large population studies in Denmark, conducted in more privileged and urbanized areas. Households were randomly selected from the Danish Civil Registration System via an index person ≥18 years, and citizens of all ages and nationalities were included. Incapacitated individuals with guardians, individuals with address protection, and individuals unable to speak Danish or English were excluded. Detailed methodology about LOFUS has been published elsewhere [19].

The data collection encompassed a comprehensive web-based questionnaire and a series of physical examinations including measurement of BMI. The questionnaire addressed multiple medical and social research domains, as well as questions about life satisfaction, measured by CLS and questions about self-reported health (SRH). Information about pregnancy was obtained at an oral interview prior to the physical examination. Data were collected from February 8, 2016, to February 13, 2020, and 18,949 (35.5%) of 53,313 invited subjects participated. The participants represented 10,280 (41%) out of 25,312 invited households (Fig. 1).

The present analyses were restricted to nonpregnant adults (18 years or older) who filled in the questionnaire, had their height and weight measured, and responded to the question about life satisfaction. The final data sample used consisted of 15,213 participants (Fig. 1).

The Cantril Ladder was invented by psychologist Hadley Cantril in 1965 as a measure of the self-reported global life satisfaction (“The Self Anchoring Striving Scale”) (Fig. 2), an 11-point scale measuring subjective global well-being and general satisfaction with life [20, 21]. Scores of 7 and above are considered high life satisfaction and scores of 6 and below are considered low life satisfaction [15, 20]. In the questionnaire, participants were asked to “imagine a ladder with steps numbered from 0 from the bottom to 10 at the top. Step 10 means the “best possible life” for you and step 0 means “the worst possible life” for you. Where on the ladder do you think you are at the present time?”

Height was measured using a wall-mounted height measure (SECA 216). Current body weight was measured using Tanita scales (Tanita Body Composition Analyzer BC-420MA III or Tanita WB 150 SMA). BMI was calculated as kg/m².

Age and sex were obtained from the Danish Civil Registration System. Educational level (basic, vocational, short, medium, high), employment status, cohabitation (living alone or not), marital status, and smoking status (smoker, nonsmoker, ex-smoker) were obtained from the questionnaire responses. Wasting disease was considered an important confounder of the association between history of weight loss and CLS, and therefore the multivariable analysis had to be adjusted for morbidity. SRH status (dichotomized good/poor) was considered at good proxy for distinguishing between healthy and unhealthy subjects [22].

Data on participant’s historical weight (5 years ago) were self-reported in the questionnaire: “How much did you weigh 5 years ago?” Olivarius et al. [23] found that recalled body weight from 5-year recall was scarcely 2 kg less than the weight in the general practitioner’s record. If these results are applicable to this study, it would cause the calculated weight loss to appear smaller than it was.

Weight change over 5 years was defined as present weight minus historical weight 5 years ago. In order to investigate the impact of 5 years weight change on the CLS, participants were divided into subgroups of “weight stable participants” (5 kg or less weight change), “participants with a weight loss” (more than 5 kilos weight loss) or “participants with a weight gain” (more than 5 kg weight gain).

Analyses were conducted using SAS 9.4. A p value level of ≤0.05 was considered as statistical significant, and 95% confidence intervals (CIs) were used. Exposures were measured BMI and self-reported 5 years weight change, and outcome was self-reported global life satisfaction with CLS. Covariates were sex, age, smoking status, cohabitation status, and education level. Since participants were household recruited, data could not be considered independent, and therefore a cluster variable indicating household belonging was included in the multivariable models.

Descriptive statistics were used to characterize the study sample. Associations between CLS and current BMI were investigated, and results were adjusted for potential confounders by multivariable analyses. Regression analyses were conducted using CLS as the dependent variable. The multivariable analyses were conducted on all participants, and stratified by participants with good SRH and participants with poor SRH. Differences in CLS between participants with a history of weight loss and participants with stable weight (as defined above) were analyzed with multivariable analysis adjusted for the earlier mentioned covariates. All data, except age and CLS, were categorical, and missing data were handled by making a category for the participants with missing values for each variable and including these missing-categories in the analyses.

Sample characteristics are shown in Table 1. The multivariable analysis revealed that higher BMI was associated with lower CLS (Table 2). For instance, having BMI 30–35 was associated with a 0.47 point (CI 0.40–0.55) lower CLS compared with BMI 18.5–25 and BMI ≥45 was associated with a 1.85 point (CI 1.45–2.25) lower CLS. Of notice, living alone was associated with a 0.45 point (CI 0.39–0.52) lower CLS and smoking was associated with a 0.53 point (CI 0.45–0.60) lower CLS.

Figure 3 displays the association between current BMI and CLS. The highest CLS was found in BMI category 18.5–25. BMI below and above was associated with lower CLS. Participants with poor SRH reported lower CLS-scores than individuals with good SRH.

Among participants with BMI ≥25 five years earlier, a history of weight loss was associated with a −0.20 (CI −0.30; −0.11) lower CLS and weight gain with a −0.34 (CI −0.40; −0.27) lower CLS compared with weight-stable individuals (Table 3). In the subsample of participants with BMI ≥25 five years earlier and a current good SRH, a history of weight gain was associated with a −0.16 (CI −0.23; −0.08) lower score, while there was no difference between the weight stable and the weight loss group (−0.05, CI −0.14; 0.05).

Among participants with BMI ≥30 five years earlier and a current good SRH, neither a history of ≥5 kg weight gain (−0.14, CI −0.29; 0.02) nor ≥5 kg weight loss (0.09, CI −0.05; 0.24) was associated with CLS compared to those with stable weight. Among participants with BMI ≥25 five years earlier and current good SRH, losing weight to BMI <25 was not associated with CLS (−0.03, CI −0.15; 0.09) compared with those who maintained a BMI ≥25. In the same subgroup of participants with BMI ≥25 five years earlier and current good SRH, the magnitude of lost weight was not associated with CLS (0.06, CI −0.09; 0.20 for ≥10 kg weight loss compared with <10 kg weight loss, and 0.10, CI −0.04; 0.24 for ≥10 kg weight loss compared with those who gained weight).

There was a strong association between current BMI and life satisfaction measured on the Cantril Ladder. The relationship between current BMI and CLS was inversely J-shaped, with lower CLS for both high and low BMI compared with BMI 18.5–25. However, among individuals with presently good SRH, the correlation between BMI and CLS was weak, indicating that BMI has little impact on life satisfaction, if the SRH is good. Overweight participants with a history of weight loss (more than 5 kg over 5 years) did not have higher life satisfaction compared with weight-stable overweight individuals. In contrast to our hypothesis, weight loss among participants with overweight was associated with a slightly lower life satisfaction or no difference compared with participants with stable overweight during 5 years (Table 3).

Satisfaction with life in relation to BMI and weight change has often been studied in weight loss interventions. The generalizability of such studies is limited due to the selection bias related to people who volunteer for a weight loss intervention. A strength in the present study is that it investigates the general population and includes individuals who may not have a current desire to change weight. The cross-sectional nature of the study is a limitation, as the direction of the causality between a high BMI and lower life satisfaction, and between history of weight change and life satisfaction cannot be inferred. It is possible that selection bias in the LOFUS cohort may have led to an overrepresentation of individuals with high life satisfaction and low BMI, as these individuals might be more likely to participate [24, 25], potentially resulting in an overestimation of the mean CLS for given BMI.

Data concerning if the weight loss was intentional or not was not available in LOFUS. Unintentional weight loss is a well-known risk factor for disease-related weight loss. Weight loss caused by wasting disease is an obvious bias as it lowers weight and likely also lowers life satisfaction. Self-rated health is a strong predictor of longevity and general health. To reduce bias from wasting disease, we included only participants with good self-rated health in our analyses of the association between weight change and the Cantril Ladder score.

Weight cycling is a major frustration for many people and may well reduce life satisfaction. However, participants with weight cycling were likely evenly distributed in the weight stable, weight gain, and weight loss groups, and therefore a potential bias in the Cantril Ladder score was probably not large. We suggest that weight cycling would result in measurement error (reducing the relative risk) rather than in a systematic error favoring life satisfaction in one weight change group.

Single-item measures as the Cantril Ladder are criticized for being nonspecific, ambiguous, vague, and unreliable to use on their own [26]. However, the present study found a robust association with BMI. The strengths of the Cantril Ladder and single-item measures in general are they are less burdensome to the participants and easy to apply in a clinical setting [27]. The Cantril Ladder reflects the individual’s concurrent and overall subjective life evaluation from his or her perspective. The subject entirely defines what the “best possible life” is in contrast to instruments exploring multiple specific variables that are expected to influence an individual’s satisfaction with life but may not necessarily affect it [21]. Measuring global life satisfaction seems rational in a biopsychosocial approach to health care, as the patient’s well-being is the primary aim [5]. The Cantril Ladder is a way of exploring the global satisfaction with life by a subjective description of the individual’s well-being unbiased of what an investigator considers a meaningful life [21].

Not many weight change studies have evaluated change in CLS. Flølo et al. [28] conducted a prospective cohort study of a highly selected group of patients with BMI >40 (and >35 with comorbidities) undergoing sleeve gastrectomy. They found an improvement in CLS 5 years after surgery, but despite maintained weight loss, CLS was still below the general population, and the improvement in CLS seemed to decrease over time, with the highest score 1 year after surgery. The authors suggested “that weight loss alone may be overemphasized in terms of improving patients’ lives” [28]. Whether the results from Flølo’s study apply to individuals with similar BMI and weight loss in the general population is uncertain. In accordance with our results, Kuroki found a robust negative association between life satisfaction (measured on a 4-point scale ranging from “Very satisfied” to “Very dissatisfied”) and body weight in US residents [29]. With data from the Nationwide Health Survey for England, Søltoft et al. [30] found that BMI was associated with HRQoL score and that most subscales of HRQoL were negatively associated with high BMI.

The present study found lower life satisfaction among individuals with BMI >25 compared with individuals with BMI <25. Whether this is due to physical aspects of a high body weight, weight-related disease, weight stigmatization, or low life satisfaction leading to weight gain, this study cannot tell.

A history of weight loss was associated with slightly lower life satisfaction score or no difference compared to individuals with a stable weight. This could reflect a true causality that life satisfaction is not achieved through weight loss. However, the finding could also be explained by residual confounding from wasting disease or stressful life events. Also, patients who were weight stable might have been more satisfied with their body and weight in the first place.

It might also be due to a general overestimation of the benefits of weight loss on life satisfaction. High BMI and weight loss both have biopsychosocial consequences, and if the high weight is a result of, or has resulted in, low life satisfaction, poor mental health, or social insecurity, a weight loss might not improve life satisfaction and general well-being [31]. This is in line with the systematic review by Kolotkin and Andersen [7], who reported inconsistent associations between weight loss interventions and improvements in HRQoL in RCTs, and a systematic review by the Danish National Board of Health that found no evidence that weight loss interventions improve life satisfaction [11]. Similar with this, Kroes et al. [32] conducted a systematic review, investigating the impact of weight change on quality of life and found higher scores on SF-36 and the Impact of Weight on Quality of Life-Lite after weight loss, and that improvements were typically only significant for physical HRQoL-domains, without improvement in the mental domains. Furthermore, a prospective study of the association between weight changes and SRH among women, found that weight loss among overweight women, did not result in an increase in SRH [33].

The present study found that life satisfaction measured on the Cantril Ladder was inversely related to BMI, with higher BMI associated with lower scores on the Cantril Ladder. The study found that among individuals with BMI >25, a history of weight loss was not associated with higher life satisfaction compared with stable overweight during 5 years. Our findings indicate that prevailing assumptions regarding weight loss and increased life satisfaction may be an oversimplification of a complex matter.

The Lolland-Falster Health Study (LOFUS), Nykøbing Falster Hospital, Denmark, is a collaboration between Region Zealand, Nykøbing Falster Hospital, and Lolland and Guldborgsund Municipalities. The authors are grateful to LOFUS for making the LOFUS research data available. However, LOFUS bears no responsibility for the analysis or the interpretation conducted within this study.

Informed written consent was obtained from all LOFUS participants. The LOFUS study was approved by the Region Zealand’s Ethical Committee on Health Research (SJ‐421) and the Danish Data Protection Agency (REG‐024‐2015). LOFUS is registered in Clinical Trials (NCT02482896).

The authors declare to have no conflicts of interest in relation to this work.

No specific funding was allocated for the present scientific work. Rasmus Køster-Rasmussen’s postdoc scholarship was financed by the Novo Nordisk Foundation.

S.F.S., R.K.-R., R.J., and T.I.A.S. conceived the study and planned the analysis and interpreted the results. R.J. was the manager of the data collection. R.K.-R. performed statistical analysis. T.I.A.S. gave input to and advice on statistical analysis. S.F.S. wrote the manuscript, while all authors contributed to the critical revision of the draft. The final draft was commented upon and approved by all authors.

Data are available upon reasonable request and are not publicly available due to ethical reasons. Data from the study can be made available via Region Sjaelland following the Danish Data Protection Regulation. Further inquiries can be directed to the corresponding author.