General practitioner views on addressing weight opportunistically in primary care: An embedded sequential mixed-methods study

A paradigm shift in cystic fibrosis nutritional care: Clinicians' views on the management of patients with overweight and obesity

BACKGROUND

Overweight and obesity among people with cystic fibrosis (pwCF) has become more prevalent since the widespread adoption of CF transmembrane conductance regulator (CFTR) modulator therapies and presents a new challenge for nutritional care. We aimed to explore how clinicians working in CF care approach the management of adults with overweight and obesity.

METHODS

We conducted semi-structured interviews with n = 20 clinicians (n = 6 physiotherapists, n = 6 doctors and n = 8 dietitians) working in 15 adult CF centres in the United Kingdom. The interviews explored their perspectives and current practices caring for people with CF and overweight/obesity. Data were analysed using reflexive thematic analysis.

RESULTS

Four main themes were identified: 1) challenges of raising the topic of overweight and obesity in the CF clinic (e.g., clinician-patient rapport and concerns around weight stigma); 2) the changing landscape of assessment due to CF-specific causes of weight gain: (e.g., impact of CFTR modulators and CF legacy diet) 3) presence of clinical equipoise for weight management due to the lack of CF-specific evidence on the consequences of obesity and intentional weight loss (e.g., unclear consequences on respiratory outcomes and risk of weight related co-morbidities) and 4) opportunities for a safe, effective, and acceptable weight management treatment for people with CF (e.g., working collaboratively with current multidisciplinary CF care).

CONCLUSIONS

Approaching weight management in the CF setting is complex. Trials are needed to assess the equipoise of weight management interventions in this group and CF-specific issues should be considered when developing such interventions.

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.

Clinician resistance to broaching the topic of weight in primary care: Digging deeper into weight management using strong structuration theory

Clinical trials have shown that providing advice and support for people with excess weight can lead to meaningful weight loss. Despite this evidence and guidelines endorsing this approach, provision in real-world clinical settings remains low. We used Strong Structuration Theory (SST) to understand why people are often not offered weight management advice in primary care in England. Data from policy, clinical practice and focus groups were analysed using SST to consider how the interplay between weight stigma and structures of professional responsibilities influenced clinicians to raise (or not) the issue of excess weight with patients. We found that general practitioners (GPs) often accounted for their actions by referring to obesity as a health problem, consistent with policy documents and clinical guidelines. However, they were also aware of weight stigma as a social process that can be internalised by their patients. GPs identified addressing obesity as a priority in their work, but described wanting to care for their patients by avoiding unnecessary suffering, which they were concerned could be caused by talking about weight. We observed tensions between knowledge of clinical guidelines and understanding of the lived experience of their patients. We interpreted that the practice of 'caring by not offering care' produced the outcome of an absence of weight management advice in consultations. There is a risk that this outcome reinforces the external structure of weight stigma as a delicate topic to be avoided, while at the same time denying patients the offer of support to manage their weight.

Delivering brief physical activity interventions in primary care: a systematic review

BACKGROUND

Physical activity (PA) brief interventions (BIs) involving screening and/or advice are recommended in primary care but frequency of delivery is unknown.

AIM

To examine the extent to which PA BIs are delivered in primary care, and explore factors associated with delivery, receipt, and patient receptivity.

DESIGN AND SETTING

A mixed-methods systematic review of studies conducted worldwide, with a narrative synthesis of results.

METHOD

CINAHL, EMBASE, MEDLINE, and APA PsycINFO index databases were searched for qualitative and quantitative studies, dating from January 2012 to June 2020, that reported the level of delivery and/or receipt of PA BIs in primary care, and/or factors affecting delivery, receipt, and patient receptivity. Quality was assessed using the Mixed Methods Appraisal Tool. Attitudes towards and barriers to delivery were coded into the Theoretical Domains Framework and the Capability, Opportunity, and Motivation Behaviour model.

RESULTS

After screening a total of 13 066 records, 66 articles were included in the review. The extent of PA screening and advice in primary care varied widely (2.4%-100% and 0.6%-100%, respectively). PA advice was delivered more often to patients with a higher body mass index, lower PA levels, and/or more comorbidities. Barriers - including a lack of time and training/guidelines - remain, despite recommendations from the World Health Organization and National Institute for Health and Care Excellence that PA advice should be provided in primary care. Few studies explored patients' receptivity to advice.

CONCLUSION

PA BIs are not delivered frequently or consistently in primary care. Addressing barriers to delivery through system-level changes and training programmes could improve and increase the advice given. Understanding when patients are receptive to PA interventions could enhance health professionals' confidence in their delivery.