Beyond Willpower: Baseline Psychological Resilience Does Not Predict Six-Month Weight Loss in Specialized Obesity Care

Rafaella Galeati Pinto et al.

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This document contributes to a growing body of research investigating the multifaceted determinants of weight management, moving beyond the traditional and often oversimplified focus on willpower as the primary driver of obesity care outcomes. Historically, the field of clinical nutrition has leaned heavily on models of self-regulation and psychological endurance, building upon established theories of health psychology that correlate high resilience with improved adherence to medical interventions. By testing the predictive power of the Resilience Scale for Adults (R.S.A) in a real-world clinical setting, this study addresses a critical gap in prospective evidence, challenging the assumption that an individual's internal capacity to adapt to stress serves as a reliable barometer for short-term weight loss success. This work serves as an essential counter-narrative to the common clinical reliance on psychological screening to forecast patient prognosis, suggesting that biological, environmental, and socio-economic factors may play significantly larger roles in chronic disease management than individual personality traits alone. Furthermore, the findings highlight a necessary shift toward systemic and multifactorial treatment models, which better reflect the complexity of obesity as a chronic, relapsing condition. By contextualizing resilience within a rigorous hospital-based cohort, the authors encourage clinicians to reconsider the diagnostic utility of psychological assessments in isolation. Ultimately, this research provides a foundation for future longitudinal studies to explore whether resilience impacts long-term weight maintenance or the prevention of weight regain, rather than just the initial weight reduction phase. As global obesity rates continue to climb, this study serves as a valuable resource for reframing clinical expectations and developing more effective, individualized support systems that prioritize sustainable metabolic health over subjective psychological measurements.

Posted Date: 17 July 2026 Preprints dot org (preprints dot org) | not Peer-reviewed | Posted: 17 July 2026

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Article

Abstract

Background/Objectives: Obesity is a chronic, multifactorial, and relapsing disease, and weight-loss outcomes should not be attributed solely to individual psychological characteristics. Psychological resilience has been proposed as a potential determinant of treatment adherence and weight-loss response, but prospective evidence in specialized obesity care remains limited. This study investigated whether baseline psychological resilience predicts six-month weight loss among adults with obesity receiving specialized outpatient care. Methods: We conducted a retrospective observational cohort study using real-world clinical data from the obesity outpatient service of a quaternary hospital in São Paulo, Brazil. The source cohort included 63 patients with six-month follow-up records. Baseline Resilience Scale for Adults (R.S.A) scores were available for 39 patients, of whom 35 had complete paired weight data and constituted the complete-case analytical cohort for the primary analysis. The primary outcome was six-month percent total body weight loss (%T.B.W.L). Associations between baseline R.S.A score and %T.B.W.L were evaluated using Spearman correlation and linear regression models, including adjustment for age, sex, and baseline body mass index. Results: In the complete-case analytical cohort, mean body weight decreased from 105.3 plus or minus 23.0 kilograms at baseline to 102.4 plus or minus 23.0 kilograms at six months. Mean absolute weight loss was 2.92 plus or minus 5.72 kilograms, corresponding to 2.71 plus or minus 5.64% T.B.W.L. Weight reduction was statistically significant by paired t-test (95% C.I 0.96 to 4.88 kilograms; p = 0.0048). Nine patients (25.7%) achieved greater than or equal to 5% weight loss, and two patients (5.7%) achieved greater than or equal to 10% weight loss. Baseline R.S.A score was not correlated with %T.B.W.L (Spearman's rho = -0.063; p = 0.718). In simple linear regression, each 10-point increase in R.S.A score was associated with a 0.03 percentage-point change in %T.B.W.L (95% C.I -1.01 to 1.07; p = 0.953). Results remained non-significant after adjustment for age, sex, and baseline B.M.I ( beta = 0.14 ; 95% C.I -1.01 to 1.30; p = 0.804). Conclusions: In this complete-case real-world cohort, baseline psychological resilience was not associated with six-month weight loss in adults with obesity receiving specialized outpatient care. These findings suggest that short-term weight-loss outcomes should not be attributed to baseline resilience or individual psychological characteristics alone. The substantial proportion of missing R.S.A data warrants cautious interpretation and highlights the need for larger prospective studies evaluating resilience in relation to adherence, persistence, long-term maintenance, and weight regain.

1. Introduction

Definition

Body Mass Index (B.M.I): A measure of body fat based on height and weight, used to categorize weight status (e.g., underweight, normal weight, overweight, obese).

Obesity is a chronic, multifactorial, and relapsing disease and one of the most pressing public health challenges of the 21st century. It is defined by the World Health Organization (who) as a body mass index (B.M.I) greater than or equal to 30 kilograms/m and classified into three severity grades: class I (B.M.I 30.0 to 34.9) kg/m squared), class 2 (B.M.I 35.0 to 39.9 kilograms/m squared), and class 3 (B.M.I greater than or equal to 40.0 kilograms/m squared). Obesity is associated with increased risk of type 2 diabetes, cardiovascular disease, hypertension, and certain cancers.

Definition

Nutritional Transition: A shift in dietary patterns and health outcomes within a population, typically moving from a diet high in unprocessed foods to one high in processed foods, often leading to increased rates of obesity and related diseases.

In Brazil, obesity prevalence increased from 11.8% in 2006 to 20.3% in 2019, with projections estimating a prevalence of 29.6% by 2030. In the city of São Paulo, prevalence rose from 11.1% to 19.8% over the same period, reflecting a rapid nutritional transition.

Definition

Psychological Resilience: The ability to mentally or emotionally adapt to stress and adversity, bouncing back from difficult experiences.

Beyond metabolic determinants, psychological factors play an important role in obesity treatment outcomes, influencing adherence, coping capacity, and long-term self-regulation. Stress has been shown to affect eating behaviours, physical activity patterns, hormonal regulation, and fat deposition, contributing to weight gain and impaired weight loss. Psychological resilience, defined as the ability to adapt and recover from stress and adversity, has emerged as a potential prognostic factor in this context.

4 Definitions

Definition 1: Self-efficacy: An individual's belief in their capacity to execute behaviors necessary to produce specific performance attainments.

Definition 2: Emotional Regulation: The ability to understand, manage, and express emotions in healthy and adaptive ways.

Definition 3: Bariatric Surgery: Surgical procedures performed on the stomach or intestines to induce weight loss, typically used for individuals with severe obesity.

Definition 4: Psychological Distress: A state of emotional suffering characterized by symptoms such as depression, anxiety, or stress.

Higher resilience is associated with adaptive coping strategies, self-efficacy, and emotional regulation, which may support healthier dietary behaviours and greater adherence to treatment. These mechanistic pathways are reflected in evidence suggesting that higher resilience is associated with improved psychological outcomes after bariatric surgery, better treatment adherence, and more favourable weight-related outcomes, whereas psychological distress is associated with poorer weight loss outcomes. Low resilience has also been identified as a marker of adverse childhood experiences and current psychological disorders in individuals with severe obesity, reinforcing its clinical relevance in this population.

3 Definitions

Definition 1: Resilience Scale for Adults (R.S.A): A self-report questionnaire used to measure psychological resilience in adults.

Definition 2: Construct Validity: A measure of validity that assesses whether a theoretical concept (construct) has been accurately measured by a test or scale.

Definition 3: Sense of Coherence: A global measure of an individual's orientation to life, encompassing comprehensibility, manageability, and meaningfulness, which contributes to coping with stress.

Psychological resilience is a multidimensional construct. In the present study, it was assessed using the Resilience Scale for Adults (R.S.A), a 33-item, six-factor self-report instrument originally developed by Friborg et al.. The R.S.A provides a comprehensive assessment of both individual and interpersonal protective factors, encompassing Perception of self, Planned future, Social competence, Structured style, Family cohesion, and Social resources. The R.S.A has been cross-culturally validated for the Brazilian population, with confirmatory factor analysis supporting the original six-factor structure and adequate construct validity, including significant negative correlation with psychiatric symptom measures and positive correlation with sense of coherence.

2 Definitions

Definition 1: Prospective Study: A study that follows a cohort of individuals over time to observe the development of outcomes or diseases.

Definition 2: Outpatient Care: Medical services provided to patients who are not admitted to a hospital.

Although resilience has been associated with psychological well-being and health behaviours, its prognostic value for clinically meaningful weight loss remains largely unknown. While some studies have reported an inverse association between resilience and B.M.I, others have observed positive or null associations, suggesting that the relationship may vary according to population characteristics and study context. Existing studies have predominantly used cross-sectional designs, and prospective evidence evaluating baseline resilience as a predictor of weight loss in specialized obesity care remains scarce. To our knowledge, no prospective study has examined whether baseline resilience measured by the R.S.A predicts weight loss outcomes in patients undergoing specialized obesity outpatient care over six months. Addressing this gap is clinically relevant, as the identification of psychological prognostic factors at the time of the initial consultation may contribute to more individualized and effective treatment strategies.

Definition

Quaternary Hospital: A highly specialized medical facility that provides advanced diagnostic and treatment services, often including tertiary care plus further specialization and research.

Therefore, this study investigated whether baseline psychological resilience assessed by the R.S.A predicts six-month weight loss among adults with obesity receiving specialized outpatient care at a quaternary hospital in São Paulo, Brazil.

2. Materials and Methods

2.1. Study Design and Setting

Definition

Retrospective Observational Cohort Study: A study that looks back at past data from a group of individuals (cohort) to identify factors associated with an outcome, without intervening in the patient's care.

This was a retrospective observational cohort study using real-world clinical data from the obesity outpatient service of the Discipline of Endocrinology, Santa Casa de Misericórdia de São Paulo, São Paulo, Brazil. Data were extracted from an institutional redcap database.

2.2. Participants

Eligible patients were identified from the institutional redcap database. Eligible patients were adults with obesity who had at least two clinical visits within a six-month follow-up window (baseline and six-month assessment), with the Resilience Scale for Adults (R.S.A) completed at the initial visit before follow-up. Obesity was defined according to the Brazilian Association for the Study of Obesity and Metabolic Syndrome (A.B.E.S.O) criteria, as B.M.I greater than or equal to 30 kilograms/m squared, or B.M.I greater than or equal to 27 kilograms/m squared in the presence of at least one obesity-related comorbidity eligible for pharmacological treatment.

No restrictions were imposed regarding anti-obesity medication class, diabetes status, or early weight-loss response.

Exclusion criteria were: age below 18 years; missing key identifiers preventing pairing of baseline and six-month data; secondary or syndromic causes of obesity (e.g., Cushing syndrome, insulinoma, lipodystrophy, Prader-Willi syndrome or Bardet-Biedel syndrome); pregnancy or lactation during follow-up; bariatric surgery or analogous surgical procedures during the observation window; and cognitive impairment precluding completion of the R.S.A.

The study protocol was approved by the Santa Casa de Misericórdia de São Paulo Ethics Committee, approval number 87515425.2.0000.5479, dated 12 April 2025. As this was a secondary analysis of routinely collected clinical data, informed consent was obtained in accordance with local regulations and the Declaration of Helsinki.

Definition

Percent Total Body Weight Loss (%T.B.W.L): A measure of weight loss calculated as the percentage of total body weight that has been lost from the starting weight.

The analytical cohort comprised N=63 patients with paired baseline and six-month assessments. Baseline Resilience Scale for Adults (R.S.A) scores were available for 39 patients (61.9%). Of these, 35 patients had complete baseline and six-month weight data and constituted the complete-case analytical cohort for the primary analysis evaluating the association between baseline R.S.A score and six-month percent total body weight loss (%T.B.W.L).

As this was a retrospective analysis of routine clinical data, the type and intensity of concomitant obesity treatment (e.g., anti-obesity pharmacotherapy class, dietary intervention, or psychological support) were not systematically recorded and could not be adjusted for in the present analysis.

2.3. Sample Size

As this was a retrospective study based on an existing clinical database, no formal sample size calculation was performed. All eligible patients meeting the inclusion criteria during the study period were included.

2.4. Data Collection and Variables

Data were collected from medical records and entered into a redcap database. For each patient, baseline variables extracted included sex, age, height, weight, waist circumference, and body mass index (B.M.I), together with the total score of the R.S.A, administered at the first clinical visit. At the six-month follow-up visit, weight, waist circumference, and B.M.I were re-assessed. Absolute weight loss (kg), change in B.M.I, and change in waist circumference were calculated as the difference between baseline and six-month values. Percent total body weight loss (%T.B.W.L) was calculated as the percentage reduction from baseline body weight.

2.5. Instrument: Resilience Scale for Adults (R.S.A)

Psychological resilience was assessed using the Resilience Scale for Adults (R.S.A), a 33-item self-report instrument originally developed by Friborg et al. [13] to measure protective resilience factors across six dimensions: Perception of self, Planned future, Social competence, Structured style, Family cohesion, and Social resources. Each item is rated on a seven-point semantic differential scale, with half of the items reverse-scored to reduce acquiescence bias; higher scores indicate higher levels of protective resilience factors. The total score is derived from the sum of all 33 items, with a theoretical range of 33 to 231 points. The R.S.A has been cross-culturally validated for the Brazilian population, with confirmatory factor analysis supporting the original six-factor structure and adequate construct validity, including significant negative correlation with psychiatric symptom measures and positive correlation with sense of coherence. For clinical interpretability in regression models, the continuous R.S.A score was additionally rescaled in 10-point units.

2.6. Statistical Analysis

Analyses were performed in Rstudio V.2024.12.1 Build 563 (Posit, Boston, M.A, U.S.A), with a two-sided significance threshold of alpha = 0.05 . Continuous variables were summarized as mean plus or minus standard deviation. Change in weight, B.M.I, and waist circumference from baseline to six months was assessed using paired t-tests, with paired Wilcoxon signed-rank tests performed as a sensitivity analysis.

Associations between baseline R.S.A score and %T.B.W.L were initially explored using Spearman's rank correlation. Variables were subsequently modelled using simple linear regression model adjusting for age, sex, and baseline B.M.I. Missing data were handled by available-case analysis for each end point.

3. Results

Among the 63 patients in the source cohort, baseline R.S.A scores were available for 39 patients (61.9%). Four of these patients lacked complete paired weight data, resulting in a complete-case analytical cohort of 35 patients for the primary analysis.

In this complete-case cohort, mean baseline body weight was 105.3 plus or minus 23.0 kilograms and mean six-month body weight was 102.4 plus or minus 23.0 kilograms. Anti-obesity medications (A.O.M) were recorded as prescribed in the first meeting, and used accordingly to clinical decision, being them Semaglutide (9/35), Sibutramine + Topiramate (7/35), Topiramate (6/35), Orlistat (5/35), Sibutramine (4/35), Bupropion + Naltrexone (3/35) and Tirzepatide (1/35). In the second meeting, other A.O.M could be prescribed – thus, the obesity treatment received during follow-up was described here, but was not included as an adjustment variable because treatment allocation was not standardized and sample size did not permit adequately powered subgroup analyses.

Complete baseline data is seen in Table 1. Tables were generated using the complete-case analytical cohort, defined as patients with available baseline R.S.A score and paired baseline and six-month body weight measurements. For outcomes with additional missingness, the number of available paired observations is shown.

Table 1 summary: Baseline characteristics for a complete-case analytical cohort of 35 participants. The group has a mean age of 47.8 plus or minus 15.2 years, with 4 males representing 11.4 percent of the cohort. Physical measurements include a mean height of 163.5 plus or minus 10.6 centimeters, a baseline body weight of 105.3 plus or minus 23.0 kilograms, and a maximum lifetime body weight of 115.1 plus or minus 23.6 kilograms. The mean baseline BMI is 39.4 plus or minus 7.5 kilograms per square meter, the baseline waist circumference for 33 available participants is 112.3 plus or minus 14.5 centimeters, and the mean baseline RSA score is 131.9 plus or minus 19.3.

Mean absolute weight loss was 2.92 plus or minus 5.72 kilograms, corresponding to a mean six-month percent T.B.W.L of 2.71 plus or minus 5.64 percent. Weight reduction was statistically significant by paired t-test (mean difference 2.92 kilograms; 95 percent C.I 0.96 to 4.88; p equals 0.0048) and was confirmed by paired Wilcoxon signed-rank test (p equals 0.0067).

Nine patients (25.7%) achieved greater than or equal to 5% weight loss, and two patients (5.7%) achieved greater than or equal to 10% weight loss. Mean B.M.I decreased by 0.82 kilograms/m squared, although this did not reach conventional statistical significance (p = 0.081). Waist circumference did not significantly decrease over six months (mean difference -3.31 centimeters; p = 0.299).

Baseline R.S.A score was not significantly correlated with six-month %T.B.W.L (Spearman's rho = -0.063; p = 0.718). In simple linear regression, each 10-point increase in baseline R.S.A score was associated with an estimated 0.03 percentage-point increase in %T.B.W.L (95% C.I -1.01 to 1.07; p = 0.953; R squared = 0.0001). After adjustment for age, sex, and baseline B.M.I, the association remained non- significant ( beta = 0.14 percentage points per 10-point R.S.A increase; 95% C.I -1.01 to 1.30; p = 0.804). In logistic regression, baseline R.S.A score was not associated with achieving greater than or equal to 5% weight loss (O.R 1.14 per 10-point increase; 95% C.I 0.73 to 1.78; p = 0.567). Figure 1 presents a graphic of logistic regression and Table 2 presents the complete changes.

Figure 1 summary: A scatter plot showing the relationship between baseline Resilience Scale for Adults (RSA) scores and six-month total body weight loss percentage. The flat regression line and wide confidence interval, supported by a Spearman's rho of -0.063 and a p-value of 0.718, indicate that there is no significant association between baseline resilience and weight loss.

Table 2 summary: Participants experienced a statistically significant reduction in body weight over six months, decreasing from a baseline of 105.3 plus or minus 23.0 kilograms to 102.4 plus or minus 23.0 kilograms, with a p-value of 0.005. Other anthropometric changes were not statistically significant, including a decrease in BMI from 39.4 to 38.5 and an increase in waist circumference from 112.3 to 116.1 centimeters. The total body weight loss was 2.7 percent plus or minus 5.6 percent, with 25.7 percent of patients achieving at least 5 percent weight loss and 5.7 percent achieving at least 10 percent weight loss.

Values are presented as mean $ \pm $ SD unless otherwise indicated.

Values are presented as mean ± SD unless otherwise indicated. Mean change represents baseline minus six-month value; therefore, positive values indicate reductions.

4. Discussion

In this retrospective cohort of patients with obesity followed at a specialized outpatient clinic, modest but statistically significant weight loss over six months was observed. However, baseline psychological resilience, assessed using the Resilience Scale for Adults (R.S.A), was not associated with six-month weight loss in either unadjusted or adjusted analyses.

The absence of association was consistent across analytic approaches, adjusting for age, sex, and B.M.I. This consistency suggests that, within this cohort, baseline R.S.A score did not demonstrate meaningful prognostic value for six-month weight loss. This finding does not necessarily indicate that psychological resilience is irrelevant to obesity management, rather, it suggests that its influence may not be expressed directly in the degree of weight change over a relatively short follow-up window.

It is plausible that six-month weight loss is influenced more directly by treatment-related and contextual factors, such as pharmacological class, dose titration, adherence, tolerability, medication access, follow-up frequency, and treatment interruptions, than by psychological traits alone. Resilience may instead be more relevant to longitudinal outcomes not captured in the present analysis, such as treatment persistence, ability to manage weight-loss plateaus, long-term adherence, or resistance to weight regain after the initial treatment phase.

These findings are consistent with the broader literature on resilience and weight-related outcomes, which remains inconsistent regarding the direction and strength of this association. While resilience has been linked to improved psychological outcomes and treatment adherence following bariatric surgery and to more favourable weight-related outcomes in other populations, and while psychological distress has been associated with poorer weight-loss outcomes, the present study did not find that resilience translated into greater six-month weight loss in a specialized obesity outpatient setting. This may reflect differences in population, treatment context, or outcome window across studies, as most prior evidence derives from cross-sectional designs, limiting direct comparison.

This study has several strengths. It employed a longitudinal follow-up design comparing baseline and six-month assessments, addressing a methodological limitation common to much of the existing literature on resilience and obesity, which is predominantly cross-sectional. Resilience was assessed using the R.S.A, a cross-culturally validated instrument for the Brazilian population, providing a multidimensional assessment of protective psychological factors. Data were derived from clinical practice at a quaternary referral centre, enhancing external validity for routine specialized obesity care.

Several limitations must be acknowledged. First, the effective analytic sample for the primary association (n = 35) was modest, limiting statistical power to detect small-to-moderate associations and increasing the risk of type 2 error. Second, missingness was substantial, particularly for the R.S.A, which was unavailable for a considerable proportion of the cohort; if incomplete scale administration was not random, this could introduce selection bias into the complete-case analysis. Third, as this was a retrospective analysis of routinely collected clinical data, information on concomitant treatment, including anti-obesity medication class, dietary intervention, and psychological or behavioural support, was not systematically recorded and could not be adjusted for, representing an important source of potential residual confounding. Fourth, the adjusted regression model included only age, sex, and B.M.I; other potentially relevant variables, such as treatment adherence, dose titration, and eating behaviour patterns, were not included. Finally, the relatively wide confidence intervals indicate limited precision in the estimated association between resilience and weight loss, and a single-centre design in a specialized quaternary-care outpatient setting may limit generalizability to primary care or community-based populations.

Future prospective studies with prospective analysis, larger samples, more complete data collection, and incorporation of treatment-related and behavioural variables are needed to clarify whether resilience is associated with clinically relevant longitudinal outcomes, such as treatment adherence, persistence, weight-loss maintenance, or resistance to weight regain. Although baseline R.S.A score did not demonstrate prognostic value for six-month weight loss in the present study, psychological assessment may remain clinically valuable for other aspects of obesity management, including treatment engagement and long-term follow-up.

5. Conclusions

In this real-world cohort of patients with obesity followed at a specialized outpatient clinic, statistically significant weight loss over six months was observed. However, baseline resilience, assessed using the R.S.A, was not associated with six-month weight loss, either in unadjusted or adjusted analyses. These findings suggest that baseline resilience, as assessed by the R.S.A, was not a predictor of six-month weight loss in this cohort. Its potential clinical relevance may instead lie in other longitudinal outcomes that were not evaluated in the present study.

These findings also support the view that short-term weight-loss outcomes cannot be explained by baseline psychological resilience alone, reinforcing the multifactorial nature of obesity and the need to avoid attributing treatment success or failure to individual psychological characteristics in isolation.

Rather than reflecting a simple expression of individual resilience or willpower, short-term weight-loss response appears to be more closely shaped by the therapeutic intervention itself and by the clinical conditions that support its implementation, continuity, and effectiveness.

Author Contributions: Conceptualization, R.G.P., R.J.P-W. and A.H.S.; methodology, R.G.P., R.J.P-W.; software, R.J.P-W.; validation, A.H.S.; formal analysis, R.J.P-W.; investigation, R.G.P. and R.J.P-W.; data curation, R.J.P-W.; writing—original draft preparation, R.G.P.; writing—review and editing, R.J.P-W.; visualization, A.H.S.; supervision, N.M.S. and J.E.N.S.; project administration, N.M.S. and J.E.N.S. All authors have read and agreed to the published version of the manuscript.

Funding: This research received no external funding.

Institutional Review Board Statement: The study protocol was approved by the Santa Casa de Misericórdia de São Paulo Ethics Committee, approval number 87515425.2.0000.5479, Date 12 April 2025. As this was a secondary analysis of routinely collected clinical data, informed consent was obtained in accordance with local regulations and the Declaration of Helsinki.

Informed Consent Statement: Informed consent was obtained from all subjects involved in the study.

Data Availability Statement: Research data is stored in Santa Casa de Misericórdia de São Paulo redcap server (redcap dot fcmsantacasasp dot edu dot br, accessed on 13 July 2026).

Acknowledgments: The authors acknowledge all Endocrinology residents from Santa Casa de Misericórdia de São Paulo for their tireless work and support, and all the patients who gladly accepted providing their information for science development.

Conflicts of Interest: The authors declare no conflicts of interest for this paper.

Abbreviations

The following abbreviations are used in this manuscript:

- R.S.A Resilience Scale for Adults

- %T.B.W.L Percent Total Body Weight Loss

- B.M.I Body Mass Index

- A.O.M Anti-obesity medication

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