The 5As team patient study: patient perspectives on the role of primary care in obesity management

'Beyond the Scale': A Qualitative Exploration of the Impact of Weight Stigma Experienced by Patients With Obesity in General Practice

OBJECTIVE

Obesity is a complex, chronic, relapsing disease that requires an individualised approach to treatment. However, weight stigma (WS) experienced in healthcare settings poses a significant barrier to achieving person-centred care for obesity. Understanding the experiences of people living with obesity (PwO) can inform interventions to reduce WS and optimise patient outcomes. This study explores how patients with obesity perceive WS in general practice settings; its impact on their psychological well-being and health behaviours, and the patients suggestions for mitigating it.

METHODS

In-depth semistructured interviews were conducted with 11 PwO who had experienced WS in general practice settings in Ireland. The interviews were conducted online via Zoom between May and August 2023; interviews lasted between 31 and 63 min (M = 34.36 min). Interviews were audio-recorded, transcribed verbatim and analysed using inductive reflexive thematic analysis.

RESULTS

Three overarching themes specific to participants' experience of WS in general practice were generated: (1) shame, blame and 'failure'; (2) eat less, move more-the go-to treatment; (3) worthiness tied to compliance. A fourth theme: (4) the desire for a considered approach, outlines the participants' suggestions for reducing WS by improving the quality of patient-provider interactions in general practice.

CONCLUSION

The findings call for a paradigm shift in the management of obesity in general practice: emphasising training for GPs in weight-sensitive communication and promoting respectful, collaborative, and individualised care to reduce WS and improve outcomes for people with obesity.

PATIENT OR PUBLIC CONTRIBUTION

PPI collaborators played an active and equal role in shaping the research, contributing to the development of the research questions, refining the interview schedule, identifying key themes in the data, and granting final approval to the submitted and published version of the study.

Transferability of the NHS low-calorie diet programme: A qualitative exploration of factors influencing the programme's transfer ahead of wide-scale adoption

INTRODUCTION

Although behavioural interventions have been found to help control type 2 diabetes (T2D), it is important to understand how the delivery context can influence implementation and outcomes. The NHS committed to testing a low-calorie diet (LCD) programme designed to support people living with excess weight and T2D to lose weight and improve diabetes outcomes. Understanding what influenced implementation during the programme pilot is important in optimising rollout. This study explored the transferability of the NHS LCD Programme prior to wider adoption.

METHODS

Twenty-five interviews were undertaken with stakeholders involved in implementing the LCD programme in pilot sites (health service leads, referring health professionals and programme deliverers). Interviews with programme participants (people living with T2D) were undertaken within a larger programme of work, exploring what worked, for whom and why, which is reported separately. The conceptual Population-Intervention-Environment-Transfer Model of Transferability (PIET-T) guided study design and data collection. Constructs of the model were also used as a deductive coding frame during data analysis. Key themes were identified which informed recommendations to optimise programme transfer.

RESULTS

Population: Referral strategies in some areas lacked consideration of population characteristics. Many believed that offering a choice of delivery model would promote acceptability and accessibility of the eligible population.

INTERVENTION

Overall, stakeholders had confidence in the LCD programme due to the robust evidence base along with anecdotal evidence, but some felt the complex referral process hindered engagement from GP practices.

ENVIRONMENT

Stakeholders described barriers to accessing the programme, including language and learning difficulties. Transferability: Multidisciplinary working and effective communication supported successful implementation.

CONCLUSION

Referral strategies to reach underrepresented groups should be considered during programme transfer, along with timely data from service providers on access and programme benefits. A choice of delivery models may optimise uptake. Knowledge sharing between sites on good working practices is encouraged, including increasing engagement with key stakeholders.

Obese patients' dissatisfaction with weight, body image and clinicians' interaction at a district hospital; Gauteng

BACKGROUND

Obesity in South Africa has created a public health crisis that warrants a multilevel intervention. However, patients' perceptions and clinicians' challenges hinder the management of obesity in primary care.

AIM

The study aimed to assess obese patients' dissatisfaction with weight and body image and their perspectives on interaction with clinicians regarding obesity management in a primary care setting.

SETTING

Outpatient department of Dr Yusuf Dadoo District Hospital.

METHODS

Cross-sectional study of 213 adult obese patients. A semi-structured questionnaire, a body image assessment tool and patients' medical records were used for data collection.

RESULTS

The study found that, contrary to popular belief, obese patients were dissatisfied with their weight (78.9%) and body image (95.3%). Many felt comfortable while discussing weight reduction with clinicians, although 37.1% reported never engaging with a doctor and 62.9% never interacted with a nurse on the subject. Only 6% reported receiving adequate information on weight reduction measures and 19.7% were followed-up. Clinicians' advice was mainly associated with patients' high body mass index and waist circumference. Doctors were less likely to recommend weight reduction to employed obese women, while nurses were more likely to engage Zulu-speaking patients. Patients were more likely to be followed up if they were young and excessively obese.

CONCLUSION

The study found that most obese patients were dissatisfied with their weight and body image and perceived their interaction with clinicians regarding obesity management as inadequate.Contribution: The study provides an angle of view of challenges in obesity management from patients' perspectives.

Health care providers' perspectives on challenges and opportunities of intercultural health care in diabetes and obesity management: a qualitative study

BACKGROUND

Migrants often face worse health outcomes in countries of transit and destination because of challenges such as financial constraints, employment problems, lack of a network of social support, language and cultural differences, and difficulties accessing health services. As understanding how the migrant context affects patient-provider engagement is critical to the provision of contextually appropriate care, this study aimed at understanding primary health care provider perspectives on challenges and opportunities of the intercultural care process for migrant patients with diabetes and obesity.

METHODS

This qualitative study within a multimethod, participatory research project involved primary care providers in clinics and primary care networks in Edmonton, Alberta, between September 2019 and February 2020. We explored health care providers' approaches to diabetes and obesity management, and experiences of and challenges with intercultural care. We conducted a thematic analysis using an interpretive qualitative approach.

RESULTS

We conducted 9 interviews and 4 focus groups and identified 3 themes: a shift from traditional weight loss-centred approaches; relationships and navigating cultural distance; and importance of and limitations in identifying and addressing root causes and barriers. Health care providers encounter considerable nonmedical challenges when supporting immigrant patients, such as navigating cultural distance and working with patients' financial constraints.

INTERPRETATION

The nonmedical challenges we identified can hinder the process of chronic disease management. Thus, in addition to educational programs and trainings to enhance the cultural competency of health care providers, incorporating avenues for cultural brokering in health care can provide invaluable support in patient-provider engagements to mitigate these challenges.

Can We Deliver Person-Centred Obesity Care Across the Globe?

PURPOSE OF REVIEW

This article discusses what person-centred care is; why it is critically important in providing effective care of a chronic, complex disease like obesity; and what can be learnt from international best practice to inform global implementation.

RECENT FINDINGS

There are four key principles to providing person-centred obesity care: providing care that is coordinated, personalised, enabling and delivered with dignity, compassion and respect. The Canadian 5AsT framework provides a co-developed person-centred obesity care approach that addresses complexity and is being tested internationally. Embedding person-centred obesity care across the globe will require a complex system approach to provide a framework for healthcare system redesign, advances in people-driven discovery and advocacy for policy change. Additional training, tools and resources are required to support local implementation, delivery and evaluation. Delivering high-quality, effective person-centred care across the globe will be critical in addressing the current obesity epidemic.

The Quality in Nutrition Care (QUINCE) model: development of a model based on Australian healthcare consumer perspectives

BACKGROUND

Primary healthcare is the ideal setting to address diet-related disease through delivery of nutrition services. However, quality nutrition care has not previously been defined from the healthcare consumer perspective.

OBJECTIVES

To explore, and develop a theoretical model of, healthcare consumer expectations of quality nutrition care in the primary healthcare setting.

METHODS

A qualitative study design collected data describing healthcare consumer expectations of nutrition care. Consumers were recruited through social media and research networks, screened, and invited to participate in a semi-structured telephone interview. Interviews explored experiences and views of nutrition care. Interviews were thematically analysed, and informed development of a model using an iterative process.

RESULTS

Twenty-three healthcare consumers participated in an interview. Five themes were identified. The Quality in Nutrition Care consumer model developed from these themes comprised 5 interconnected components, these being: (i) quality nutrition care occurs within an integrated societal system; (ii) quality nutrition care is available, accessible, and affordable; (iii) quality nutrition care is up-to-date and evidence based; (iv) quality nutrition care is underpinned by positive relationships; and (v) quality nutrition care is personalized to consumer needs.

CONCLUSIONS

The consumer-derived model of quality nutrition care can be used by providers to inform activities that enhance primary healthcare practice, outcomes, and impact. The model has important implications for primary healthcare system reform and policy. Future research should explore the provision of dietetic services in primary care, with specific focus on factors that influence quality care, and investigate how quality is monitored and improved.

People with weight-related long-term conditions want support from GPs: A qualitative interview study

Two-thirds of UK adults do not have an up-to-date weight record in primary care. Some studies suggest that doctors do not raise the topic of weight management for fear of causing embarrassment or offence, or are doubtful whether people will make changes. However, for people with weight-related long-term conditions, conversations with general practitioners (GPs) can be crucial. Our study explores how people with long-term conditions associated with overweight recall and interpret conversations about weight in British primary care. An experienced qualitative researcher interviewed 41 people aged <42 years with long-term conditions associated with overweight. A maximum variation sample was sought, and transcribed interviews were analysed thematically. We revealed that patients with weight-related long-term conditions have different experiences and expectations about the role of GPs in supporting weight management. If a GP did not raise weight management in the context of the long-term condition patients formed the impression that their overweight was not seen as "doctorable" that is, as an appropriate topic for the consultation, rather than a personal or "lifestyle" concern. This was explained in multiple ways, which are captured in two themes; perceiving weight as "doctorable"; and weight doctoring in primary care. The findings highlight the need for increased attention on weight-related long-term conditions in primary care. Interventions from GPs would be welcome if conducted in a sensitive, non-judgmental manner and based on sound evidence about what works.

Contextually Appropriate Tools and Solutions to Facilitate Healthy Eating Identified by People with Type 2 Diabetes

Type 2 diabetes (T2D) is a complex, multifaceted disease and its treatment involves lifestyle intervention (LI) programs that participants may find difficult to adopt and maintain. The objective of this study is to understand the lived experiences of participants with T2D regarding healthy eating behavior change, in order to identify and incorporate relevant information, skills, and educational approaches into LI programs. An explorative qualitative study was undertaken. Purposeful sampling was used to recruit 15 participants. One-on-one, semi-structured, open-ended, and in-depth interviews were conducted. An essentialist paradigm was adopted to accurately report the experiences, meaning, and reality of participants. An inductive approach was used to analyze the data. Participants reported that being diagnosed and living with T2D could be overwhelming, and their ability to manage was influenced by health care providers (HCP), family, and individual context. Many experienced a loop of “good–bad” eating behaviors. Participants expressed desires for future diabetes management that would include program content (nutrition, physical activity, mental health, foot care, and consequences of T2D), program features (understand context, explicit information, individualized, hands-on learning, applicable, realistic, incremental, and practical), program components (access to multidisciplinary team, set goals, track progress and be held accountable, one-on-one sessions, group support, maintenance/follow-up), and policy change. In conclusion, the results of this study indicate that T2D management requires more extensive, comprehensive, and ongoing support, guided by the individual participant.

Obesity Management Education Needs Among General Internists: A Survey

Objective

The purpose of this study was to determine self-reported knowledge, attitudes, prior experience, and perceived needs for the management of overweight and obese patients within a General Internal Medicine Practice.

Patients and Methods

An emailed cross-sectional survey was sent between June 20, 2019 and September 12, 2019 to 194 healthcare workers (93 primary care providers (PCPs) and 101 nurses) which focused on management of patients with weight issues.

Results

In total, 80 of the eligible 194 participants completed the survey (nurses = 42, PCPs = 38). Up to 87% were white, 74.7% female (74.7%). Most of the responders were either in the age group of 30’s (30%) or 50’s (30%). Among the responders, 48.8% reported some type of specialty training in weight management since their medical training with lectures being the most common form of training (36%). When asked about their interest in either weight management training or strategies to initiate weight conversations, 79% of the respondents reported an interest in education on weight management or strategies to initiate weight conversations, while 65.8% indicated they would be interested in both topics.

Conclusion

Our study suggests that healthcare workers have a self-reported need for further training in management of overweight and obese patients, irrespective of previous training in this area.

A Community Jury on initiating weight management conversations in primary care

Background

Current guidelines recommend that patients attending general practice should be screened for excess weight, and provided with weight management advice.

Objective

This study sought to elicit the views of people with overweight and obesity about the role of GPs in initiating conversations about weight management.

Methods

Participants with a body mass index ≥25 were recruited from a region in Australia to take part in a Community Jury. Over 2 days, participants (n = 11) deliberated on two interconnected questions: ‘Should GPs initiate discussions about weight management?’ And ‘if so, when: (a) opportunistically, (b) in the context of disease prevention, (c) in the context of disease management or (d) other?’ The jury deliberations were analysed qualitatively to elicit their views and recommendations.

Results

The jury concluded GPs should be discussing weight management, but within the broader context of general health. The jury were divided about the utility of screening. Jurors felt GPs should initiate the conversation if directly relevant for disease prevention or management, otherwise GPs should provide opportunities for patients to consent to the issue being raised.

Conclusion

The jury's verdict suggests informed people affected by overweight and obesity believe GPs should discuss weight management with their patients. GPs should feel reassured that discussions are likely to be welcomed by patients, particularly if embedded within a more holistic focus on person‐centred care.

Public contribution

Members of the public took part in the conduct of this study as jurors, but were not involved in the design, analysis or write‐up.

Putting the Patient First: A Scoping Review of Patient Desires in Canada

Patient-centred care is a key priority for governments, providers and stakeholders, yet little is known about the care preferences of patient groups. We completed a scoping review that yielded 193 articles for analysis. Five health states were used to account for the diversity of possible preferences based on health needs. Five broad themes were identified and expressed differently across the health states, including personalized care, navigation, choice, holistic care and care continuity. Patients' perspectives must be considered to meet the diverse needs of targeted patient groups, which can inform health system planning, quality improvement initiatives and targeting of investments.

Provider Advice and Patient Perceptions on Weight Across Five Health Systems

INTRODUCTION

To improve the management of overweight and obesity in the primary care setting, an analysis of patient perceptions of weight status and predictors of weight loss attempts for those with overweight and obesity is needed.

METHODS

Primary care patients (n=949) across 5 health systems in the Mid-Atlantic region of the U.S. were surveyed in 2015; data analysis was performed in 2018. Survey data was combined with data via the electronic health record to understand patients' perceptions of weight, factors associated with weight loss efforts, and provider counseling practices.

RESULTS

Most participants with overweight or obesity perceived themselves as weighing too much and reported trying to lose weight. Furthermore, most participants with obesity reported receiving advice to lose weight by a provider in the past 12 months. However, less than half of patients with overweight reported receiving advice to lose weight, maintain weight, or develop healthy eating and physical activity patterns from a health professional in the past 12 months. Among participants with overweight and obesity, multivariable logistic regression analysis demonstrated that the perception of being overweight and receiving healthcare advice to lose weight had the highest odds of reporting attempted weight loss (OR=5.5, 95% CI=2.7, 11.2 and OR=3.9, 95% CI=1.9, 7.9, respectively).

CONCLUSIONS

The findings emphasize the importance of provider attention to weight management counseling and identifies patients with overweight as needing increased attention by providers.

Weight assessment and the provision of weight management advice in primary care: a cross-sectional survey of self-reported practice among general practitioners and practice nurses in the United Kingdom

Background

Although primary care settings provide a large-scale and high-reach opportunity for weight management and obesity prevention, the proportion of adults in the United Kingdom (UK) who report receiving weight management advice is limited. This study examines the self-reported frequency of assessing weight and providing weight management advice by General Practitioners (GPs) and Practice Nurses (PNs) working in primary care in the UK, and differences by practitioner characteristics.

Methods

Cross-sectional survey with GPs and PNs in the UK (n = 2020), conducted January–March 2017. A mock consultation exercise assessed what factors led to calculating a patient’s Body Mass Index (BMI) and whether weight management advice was given after determining the patient had an obese BMI. For all patients, practitioners were asked how often they calculated BMI, how often they gave weight management advice to patients with an obese BMI, and how often they utilised different advice or referral options (each: Always/Often vs. Less often/Never). Binary logistic regressions examined whether frequency of assessing weight and providing advice was associated with practitioner characteristics.

Results

In the mock consultation, physical cues (40%) were most likely to prompt calculation of BMI, and half of practitioners (56%) provided weight management advice after determining the patient had an obese BMI, with GPs less likely to do so than PNs (Odds Ratio [OR] = 0.59, 95% CI: 0.47–0.75). Half of practitioners (58%) said they calculated the BMI of all patients Always/Often, with GPs less likely to do so than PNs (OR = 0.27, 95% CI: 0.21–0.34). Three quarters (78%) said they provided weight management advice to patients with an obese BMI Always/Often, with GPs less likely to do so than PNs (OR = 0.63, 95% CI: 0.47–0.85). Weight management advice was provided more frequently than referrals, particularly suggesting increased physical activity (93%) and diet modification (89%).

Conclusions

Consistent with previous research, the findings suggest that opportunities to provide weight management advice in primary care, including to patients with an obese BMI, are potentially missed. Future research should test alternative mechanisms to increase weight assessment and advice provision, examine the effectiveness of advice frequently given, and seek solutions to reported barriers for providing weight management advice.

Primary care patient and practitioner views of weight and weight-related discussion: a mixed-methods study

OBJECTIVE

To understand the beliefs that primary care practitioners (PCPs) and patients with overweight and obesity have about obesity and primary care weight management in Scotland.

SETTING

Seven National Health Service (NHS) Scotland primary care centres.

PARTICIPANTS

A total of 305 patients and 14 PCPs (12 general practitioners; two practice nurses) participated.

DESIGN AND METHODOLOGY

A cross-sectional mixed-methods study. PCPs and patients completed questionnaires assessing beliefs about obesity and primary care weight communication and management. Semi-structured interviews were conducted with PCPs to elaborate on questionnaire topics. Quantitative and qualitative data were synthesised to address study objectives.

RESULTS

(1) Many patients with overweight and obesity did not accurately perceive their weight or risk of developing weight-related health issues; (2) PCPs and patients reported behavioural factors as the most important cause of obesity, and medical factors as the most important consequence; (3) PCPs perceive their role in weight management as awareness raising and signposting, not prevention or weight monitoring; (4) PCPs identify structural and patient-related factors as barriers to weight communication and management, but not PCP factors.

CONCLUSIONS

Incongruent and/or inaccurate beliefs held by PCPs and patient may present barriers to effective weight discussion and management in primary care. There is a need to review, standardise and clarify primary care weight management processes in Scotland. Acknowledging a shared responsibility for obesity as a disease may improve outcomes for patients with overweight and obesity.

Dietitians' Perspectives on the Impact of Multidisciplinary Teams and Electronic Medical Records on Dietetic Practice for Weight Management

Purpose: To understand the perception of dietitians regarding the effects of multidisciplinary settings and Electronic Health Records (EHRs) on their dietetic practice for weight management. Methods: Individual semi-structured interviews were conducted with 14 dietitians working in multidisciplinary settings in Ontario. All interviews were audio recorded and transcribed verbatim. Two researchers coded the data independently using a thematic analysis approach. All themes emerged inductively and were refined iteratively. Results: Most dietitians believed that working in a multidisciplinary setting allowed for interprofessional collaboration and time-effective referrals. Multidisciplinary clinics were perceived to improve patient care due to convenient scheduling, consistent messaging, and ongoing support. However, some dietitians reported instances of conflicting approaches and beliefs regarding weight management across health professionals. Dietitians suggested ways to address these conflicting approaches through clinical meetings and education. EHRs were perceived to allow for collaboration through facilitated communication and knowledge exchange; however, lack of interoperability between EHR platforms across different types of health care settings was perceived to be a barrier for optimal care. Conclusions: Overall, multidisciplinary settings were perceived to positively impact dietitians' practices for weight management as they allow for interprofessional collaboration. Consistency in health messaging across health professionals should be emphasized through knowledge exchange.

Clinical encounters about obesity: Systematic review of patients' perspectives

Guidelines recommend clinicians intervene on obesity but it is unclear how people with overweight react. In this systematic review, we searched 20 online databases for qualitative studies interviewing people with overweight or obesity who had consulted a primary care clinician. Framework synthesis was used to analyse 21 studies to produce a new theoretical understanding. Consultations in which patients discussed their weight were more infrequent than patients would have liked, which some perceived was because they were unworthy of medical time; others that it indicated doctors feel being overweight is not a serious risk. Patients reported that doctors offered banal advice assuming that the patient ate unhealthily or was not trying to address their weight. Patients reported doctors assumed that their symptoms were due to overweight without a proper history or examination, creating concern that serious illness may be missed. Patients responded positively to offers of support for weight loss and active monitoring of weight. Patients with overweight internalize weight stigma sensitizing them to clues that clinicians are judging them negatively, even if weight is not discussed. Patients' negative experiences in consultations relate to perceived snap judgements and flippant advice and negative experiences appear more salient than positive ones.

Improving obesity management training in family medicine: multi-methods evaluation of the 5AsT-MD pilot course

BACKGROUND

Quality, evidence-based obesity management training for family medicine residents is needed to better support patients. To address this gap, we developed a comprehensive course based on the 5As of Obesity Management™ (ASK, ASSESS, ADVISE, AGREE, ASSIST), a framework and suite of resources to improve residents' knowledge and confidence in obesity counselling. This study assessed the course's impact on residents' attitudes, beliefs, and confidence with obesity counselling.

METHODS

The course combines lectures with a bariatric empathy suit experience, standardized and in-clinic patient practice, and narrative reflections. Using a multi-methods design we measured changes in 42 residents' attitudes, beliefs, and self-confidence and thematically analyzed the narrative reflections to understand residents' experience with the course content and pedagogy.

RESULTS

Following the course, residents reported improved attitudes towards people living with obesity and improved confidence for obesity counselling. Pre/post improvement in BAOP scores (n = 32) were significant (p < .001)., ATOP scores did not change significantly. Residents showed improvement in assessing root causes of weight gain (p < .01), advising patients on treatment options (p < .05), agreeing with patients on health outcomes (p < .05), assisting patients in addressing their barriers (p < .05), counseling patients on weight gain during pregnancy, (p < .05), counseling patients on depression and anxiety (p < .01), counseling patients on iatrogenic causes of weight gain (p < .01), counseling patients who have children with obesity (p < .05), and referring patients to interdisciplinary providers for care (p < .05). Qualitative analysis of narrative reflections illustrates that experiential learning was crucial in increasing residents' ability to empathically engage with patients and to critically reflect on implications for their practice.

CONCLUSION

The 5AsT-MD course has the potential to increase residents' confidence and competency in obesity prevention and management. Findings reflect the utility of the 5As to improve residents' confidence and competency in obesity management counselling.

Perceptions of barriers to effective obesity management in Canada: Results from the ACTION study

Obesity is a chronic disease with a significant and growing impact on Canadians. The "Awareness, Care and Treatment In Obesity MaNagement" (ACTION) Study investigated perceptions, attitudes and perceived barriers to obesity management among Canadian people with obesity (PwO), healthcare providers (HCPs) and employers. In this study adult PwO (body mass index ≥30 kg/m² , based on self-reported height/weight), HCPs (physicians and allied HCPs managing PwO) and employers (≥20 employees; offering health insurance), completed online surveys between 3 August and 11 October 2017 in a cross-sectional design. Survey respondents (N = 2545) included 2000 PwO, 395 HCPs and 150 employers. Obesity was viewed as a "chronic medical condition" by most PwO (60%), HCPs (94%) and employers (71%) and deemed to have a large impact on overall health (74%, 78%, 81%, respectively). Many PwO (74%) believed weight management was their own responsibility. While PwO (55%) reportedly knew how to manage their weight, only 10% reported maintaining ≥10% weight reduction for >1 year. Despite low success rates, the most commonly reported effective long-term weight loss methods tried and/or recommended were "improvements in eating habits" (PwO 38%; HCP 63%) and "being more active" (PwO 39%; HCP 54%). PwO and HCPs reported very different perceptions of the quality and content of their interaction during obesity management discussions. These findings highlight the communication gaps and misunderstanding between PwO, HCPs and employers. This underscores the importance of, and need for, evidence-based management of obesity and a collaborative approach and understanding of the complex nature of this chronic disease.

Factors affecting access and use of preventive and weight management care: A public health lens

Obesity is an important risk factor for various chronic diseases. While people with obesity use the health system more and incur higher costs, they may forego using preventive care services (e.g., gynecological cancer screenings) due to issues of service use and service access. The aim of this paper was to use a public health lens to elucidate system level factors that affect healthcare access and utilization for preventive and weight management care by patients with obesity. Some elucidated factors include lack of access to a Primary Care Provider (PCP) and multidisciplinary healthcare settings, gender of the PCP, duration of medical visits and health professionals' attitudes about obesity. We highlight potential strategies for leaders to use when improving access and use of health services by patients with obesity in Canada and the need for future empirical studies in this research area.

Dietitians' perspectives on patient barriers and enablers to weight management: An application of the social-ecological model

AIM

Dietitians are nutrition experts who conduct nutrition assessments and provide support to patients seeking to manage their weight. The aim of the present study was to assess dietitians' perspectives on the barriers and enablers encountered by patients during their weight management journey.

METHODS

Fourteen individual semi-structured interviews were conducted over a 3-month period in 2017 with dietitians working in Ontario, Canada. All interviews were audio-recorded and transcribed verbatim. Two researchers coded the data independently using a directed content analysis approach.

RESULTS

Emerging themes were classified at societal, community, relationship, individual levels of the social-ecological model (SEM). Barriers included low socioeconomic status, 'go big or go home approach', lack of knowledge and cooking skills, lack of time, emotional eating, unsupportive home and work environments, discrimination and weight bias, lack of communication between health professionals, and low accessibility to healthy foods. Enablers included community programs, workplaces promoting healthy behaviours, and ongoing clinical support. Dietitians mentioned that patients encounter many barriers that may coexist and hinder weight management and/or maintenance of lost weight.

CONCLUSIONS

Communication between health team members and ongoing patient support in the clinical setting are required. A whole-of-government, whole-of-society approach is needed to target the various aforementioned barriers at various level of the SEM.

Associations between Lifetime Adversity and Obesity Treatment in Patients with Morbid Obesity

BACKGROUND

Bariatric surgery is associated with greater and more sustainable weight loss compared with lifestyle intervention programs. On the other hand, bariatric surgery may also be associated with physical and psychosocial complications. The influence of psychological evaluation on treatment choice, however, is not known. We aimed to examine variables associated with treatment choice and, specifically, if self-reported lifetime adversity influenced obesity treatment, i.e. bariatric surgery, high-intensive lifestyle treatment or low-intensive lifestyle treatment in primary care.

METHODS

We consecutively included 924 patients from the registry study of patients with morbid obesity at Akershus University Hospital, Lørenskog, Norway. Treatment selection was made through a shared decision-making process. Self-reported lifetime adversity was registered by trained personnel. Logistic regression models were used to assess the associations between obesity treatment and possible predictors.

RESULTS

Patients who chose bariatric surgery were more likely to have type 2 diabetes (DM2) compared with patients who chose lifestyle treatment (bariatric surgery: 35%, high-intensive lifestyle treatment: 26%, and low-intensive lifestyle treatment: 26%; p = 0.035). Patients who chose bariatric surgery were less likely than patients who chose lifestyle intervention to report lifetime adversity (bariatric surgery: 39%, high-intensive lifestyle treatment: 47%, and low-intensive lifestyle treatment: 51%; p = 0.004). After multivariable adjustments, increasing BMI, having DM2, and joint pain were associated with choosing bariatric surgery over non-surgical obesity treatment (odds ratio [95% CI]: BMI 1.03 [1.01-1.06], DM2 1.47 [1.09-1.99], and joint pain 1.46 [1.08-1.96]). Self-reported lifetime adversity was furthermore associated with lower odds of choosing bariatric surgery in patients with morbid obesity (0.67 [0.51-0.89]).

CONCLUSION

This study shows that increasing BMI, DM2, and joint pain were all associated with treatment choice for obesity. In addition, self-reported lifetime adversity was associated with the patients' treatment choice for morbid obesity. Consequently, we suggest that decisions concerning obesity treatment should include dialogue-based assessments of the patients' lifetime adversity.

Personalizing obesity assessment and care planning in primary care: patient experience and outcomes in everyday life and health

Obesity is a complex, chronic disease, frequently associated with multiple comorbidities. Its management is hampered by a lack of translation of evidence on chronicity and pathophysiology into clinical practice. Also, it is not well understood how to support effective provider-patient communication that adequately addresses patients' personal root causes and barriers and helps them feel capable to take action for their health. This study examined interpersonal processes during clinical consultations, their impacts, and outcomes with the aim to develop an approach to personalized obesity assessment and care planning. We used a qualitative, explorative design with 20 participants with obesity, sampling for maximum variation, to examine video-recorded consultations, patient interviews at three time points, provider interviews and patient journals. Analysis was grounded in a dialogic interactional perspective and found eight key processes that supported patients in making changes to improve health: compassion and listening; making sense of root causes and contextual factors in the patient's story; recognizing strengths; reframing misconceptions about obesity; focusing on whole-person health; action planning; fostering reflection and experimenting. Patient outcomes include activation, improved physical and psychological health. The proposed approach fosters emphatic care relationships and sensible care plans that support patients in making manageable changes to improve health.

Five A's counseling in weight management of obese patients in primary care: a cluster-randomized controlled trial (INTERACT)

BACKGROUND

Obesity is one of the most prevalent health problems in western societies. However, it seems not effectively managed in the healthcare system at present. Originating from smoking cessation a tool called the 5As for obesity management has been drafted and adapted by the Canadian Obesity Network (CON) to improve weight counseling and provider-patient-interaction. This paper describes the rationale and design of the INTERACT study. The objective of the INTERACT study is to evaluate the effectiveness and intervention costs of a 5As eLearning program for obesity management aimed specifically at general practitioners (GPs).

METHODS

The INTERACT study is a cluster randomized controlled trial aimed at implementing and evaluating an online-tutorial for obesity management based on the 5As approach in cooperating primary health care practices. Effectiveness of the 5As intervention will be evaluated by assessing patients and doctors perspectives on obesity management in primary care before and after the training. GPs in the intervention group will get access to the 5As obesity management online-tutorial while GPs in the control group will be assigned to a waiting list. Outcome measures for patients and GPs will be compared between the intervention group (treatment as usual + training of the GP) and the control group (treatment as usual). Hierarchical regression models will be used to analyze effects over time pre- and post-intervention.

DISCUSSION

The 5As present physicians with a simple mnemonic for patient counseling in the primary care context. While the use of the 5As in weight counseling seems to be associated with improved doctor-patient interaction and motivation to lose weight, intervention studies assessing the effectiveness of a short 5A eLearning tutorial for physicians on secondary outcomes, such as weight development, are lacking.

TRIAL REGISTRATION

The study has been registered at the German Clinical Trials Register ( DRKS00009241 ; date of registration: 03.02.2016).

Obesity Prevention and Management Strategies in Canada: Shifting Paradigms and Putting People First

PURPOSE OF REVIEW

The purpose of this study was to review public and private sector obesity policies in Canada and to make recommendations for future evidence-based obesity prevention and management strategies.

RECENT FINDINGS

Synthesis of obesity prevention and management policies and research studies are presented in three primary themes: (1) Increased awareness about the impact of weight bias and obesity stigma in Canada; (2) Inadequate government obesity prevention and management policies and strategies; and (3) Lack of comprehensive private sector obesity prevention and management policies. Findings suggest that in Canada, obesity continues to be treated as a self-inflicted risk factor, which affects the type of interventions and approaches that are implemented by governments or covered by private health plans. The lack of recognition of obesity as a chronic disease by Canadian public and private payers, health systems, employers, and the public, has a trickle-down effect on access to evidence-based prevention and treatment. Although there is increasing recognition and awareness about the impact of weight bias and obesity stigma on the health and social well-being of Canadians, interventions are urgently needed in education, healthcare, and public policy sectors. We conclude by making recommendations for the advancement of evidence-based obesity prevention and management policies that can improve the lives of Canadians affected by obesity.

Clinical Obesity Services in Public Hospitals in Australia: a position statement based on expert consensus

We aimed to describe the current state of specialist obesity services for adults with clinically severe obesity in public hospitals in Australia, and to analyse the gap in resources based on expert consensus. We conducted two surveys to collect information about current and required specialist obesity services and resources using open-ended questionnaires. Organizational level data were sought from clinician expert representatives of specialist obesity services across Australia in 2017. Fifteen of 16 representatives of current services in New South Wales (n = 8), Queensland (n = 1), Victoria (n = 2), South Australia (n = 3), and the Australian Capital Territory (n = 1) provided data. The composition of services varied substantially between hospitals, and patient access to services and effective treatments were limited by strict entry criteria (e.g. body mass index 40 kg/m² or higher with specific complication/s), prolonged wait times, geographical location (major cities only) and out-of-pocket costs. Of these services, 47% had a multidisciplinary team (MDT), 53% had an exercise physiologist/physiotherapist, 53% had a bariatric surgeon and 33% had pharmacotherapy resources. Key gaps included staffing components of the MDT (psychologist, exercise physiologist/physiotherapist) and access to publicly funded weight loss pharmacotherapy and bariatric surgery. There was consensus on the need for significant improvements in staff, physical infrastructure, access to services, education/training in obesity medicine and targeted research funding. Based on the small number of existing, often under-resourced specialist obesity services that are located only in a few major cities, the vast majority of Australians with clinically severe obesity cannot access the specialist evidence based treatments needed.

Nutrition care practices of primary care providers for weight management in multidisciplinary primary care settings in Ontario, Canada - a qualitative study

Background

Despite the recommended guidelines on addressing diet for the management and prevention of obesity in primary care, the literature highlights that their implementation has been suboptimal. In this paper, we provide an in-depth understanding of current nutrition-related weight management practices of primary care providers (PCPs) working in relatively new multidisciplinary health care settings in Ontario.

Methods

Three types of multidisciplinary primary care settings were included (2 Family Health Teams, 3 Community Health Centres and 1 Nurse Practitioner-Led Clinic). Participants (n = 20) included in this study were nurse practitioners (n = 13) and family physicians (n = 7) supporting care for adult patients (18 years or older). In-depth interviews were transcribed, coded and the content was analyzed using an integrated approach.

Results

Our analysis showed that most PCPs used anthropometric measures such as weight for screening patients who would benefit from nutrition counselling with a dietitian. The topic of nutrition was generally brought up either during physical examinations, when patients were diagnosed with a chronic disease, or when blood markers were out of normal range. Participants also mentioned that physical examinations are no longer occurring annually, with most PCPs offering episodic care. All participants reported utilizing dietetic referrals, noting the enablers for providing the referral, which included access to an on-site dietitian. Nonetheless, dietetic referrals were mostly used when patients had an obesity-related co-morbidity. Participants mentioned that healthy eating advice was reinforced during follow-up visits with patients only when there was enough time to do so. Electronic Health Records (EHRs) were utilized to facilitate message reinforcement by PCPs, who perceived EHRs to be helpful for viewing what was discussed in the session with the dietitian.

Conclusions

PCPs mostly used objective measures to screen for patients who would benefit from nutrition counselling rather than diet assessment, which undermines the importance of dietary intake and overemphasizes weight. With physical examinations occurring less frequently, there will be additional missed opportunities for addressing nutrition-related concerns. The presence of a dietitian on site allowed for PCPs to refer patients to nutrition counselling. Having sufficient time during medical visits and EHRs seemed to facilitate message reinforcement by PCPs in follow-up visits with patients.

Electronic supplementary material

The online version of this article (10.1186/s12875-018-0760-3) contains supplementary material, which is available to authorized users.

Current Weight Management Approaches Used by Primary Care Providers in Six Multidisciplinary Healthcare Settings in Ontario

BACKGROUND

Obesity management in primary care has been suboptimal due to lack of access to allied health professionals, time, and resources.

PURPOSE

To understand the weight management approaches used by primary care providers working in team-based settings and how they assess the most suitable approach for a patient.

METHODS

A total of 20 primary care providers (13 nurse practitioners and 7 family physicians) working in 6 multidisciplinary clinics in Ontario were interviewed. All interviews were recorded, transcribed verbatim, and coded using NVivo qualitative software. Conventional content analysis was used to inductively elucidate codes, which were then clustered into categories.

RESULTS

A referral to on-site programming was the most frequent weight management approach used. The pharmacological approach was underutilized due to adverse side effects and cost to patients. Primary care providers assessed the most suitable weight management approach based on patients': preference, level of motivation, income status and access to resources, body mass index and comorbidities, and previous weight loss attempts. Primary care providers perceived that referring to health professionals and educational resources were the approaches preferred by patients.

CONCLUSIONS

The team-based nature of these clinics allowed for referrals to various on-site professionals and/or programs. Some barriers to pursuing weight management avenues with patients were patient dependent.