Results from a qualitative interview series
What care needs do overweight and obese patients have in primary care?
a Institute: Centre for General Medicine and Geriatrics, University Medical Centre of the Johannes Gutenberg University Mainz, Germany
Background: General practitioners (GPs) can play a major role in overweight and obese patient counselling and management. Longstanding doctor-patient relationships give GPs a wide range of options for treating obesity issues. So far, there is a lack of information on experiences amongst overweight and obese patients in general practice as well as the care needs and desires of patients from GPs. The aim of this study was to explore the experiences of overweight and obese patients as well as their needs and desires in general practice. The study will then use the results to determine starting points for optimising the GP setting.
Methods: We recruited a total of 36 people affected by obesity through 24 online health forums. Then we conducted qualitative interviews with overweight and obese patients between January and November 2021.
Results: The interviewees saw GPs as their central point of contact for counselling and support in weight issues. Counselling from GPs showed a positive relationship with increased motivation towards weight reduction. However, interviewees reported widespread weaknesses despite this positive perception: 1) incidental or delayed determination of obesity; 2) lack of ongoing weight counselling; 3) failure to reach agreement on specific weight-loss targets; 4) lack of referral to assistance and support services; 5) insensitivity in discussing the issue. Only some interviewees that had achieved sustained weight loss attributed their success to support provided by their GPs.
Conclusions: The study indicates that general practice cannot currently exploit its full potential in obesity management. GPs should be encouraged to address obesity promptly and consistently. Management strategies should include specific recommendations and realistic weight-loss targets. Continuous motivational counselling plays a major role in positive outcomes. Focussed diet and exercise counselling would also be advisable. GPs should be encouraged to take on a role as mediators by referring patients to a broader healthcare network, as necessary. The development of obesity management care programmes within the remit of general practice should be pursued.
In Germany, 53% adults are overweight, 17% of which are obese [1–4]. Obesity plays a dominant role in 80% of type 2 diabetes, 35% of ischaemic heart disease and 50% of hypertensive disease cases in Europe [1, 3, 5–7].
Apart from their role in providing consultation and support, general practitioners (GPs) have various options available to ensure that obese patients reach their weight reduction targets by lifestyle changes [7–11]. These options include exercise and diet counselling, therapeutic intervention or referrals for psychosocial intervention .
Studies have indicated that GPs have often been found to hold negative attitudes towards severely overweight patients, like assuming a lack of willpower [9, 12–15]. Some GPs showed a corresponding lack of trust in the effectiveness of diet or exercise therapy [16–18]. Lack of adequate structures has also been discussed as a reason for reticence amongst GPs [19–21].
Results from studies so far have varied greatly on the willingness of obese patients to seek advice and therapeutic support from GPs. In several Western countries, GPs play a major mediating role in weight management and patients welcomed regular counselling from their GPs on diet and exercise to be motivated to change their lifestyle [11, 22–26]. Other studies have found that patients complained that GPs did not give any specific recommendations after diagnosing obesity [27, 28].
The German-speaking world has no current studies focused on obesity management by GPs. This contribution addresses the question of how obese patients experience GP support and what needs they have regarding obesity management. The findings will be used to develop starting points for optimising the GP setting.
Material and methods
We used a qualitative approach with individual semi-structured interviews.
Addressing the issue involved drawing up a guideline (appendix 1) based on relevant desk research [1, 2, 7, 9, 15, 18–21, 29, 38] while also taking a preliminary study into account .
Participants were recruited through 24 online health forums focused on overweight. Forum participants ready to be available for interview were given an e-mail address to reply to.
We recruited a total of 40 potential interviewees on a voluntary basis from 16 of the 24 forums from whom we collected data on height, weight, age, gender and living environment in advance. The inclusion criterion was unambiguous overweight, defined as a BMI of more than 25 kg/m2 according to a physician or other health professional in the last two years.
Thirty-six subjects with the highest stated bodyweight were selected from the pool and enrolled in the study.
The authors conducted all interviews between January and November 2021. We offered the interviewees the option to conduct the interview via online chat in addition to telephone interviews.
Theoretical saturation became apparent after 25 interviews.
After data collection, the first author evaluated the resulting transcripts using qualitative content analysis using MAXQDA . This first entailed pinpointing the key statements, which was followed by further abstraction and summarisation leading to a categorised system (appendix 2) closely based on the guideline.
Experiences with general practice
Thirty-two interviewees valued the support from their own GP towards losing weight and promoting a healthy lifestyle more than recommendations from other doctors or health professionals. Thirty-four interviewees reported that they had already discussed their weight with their current or a previous GP. Weight counselling sometimes took place during medical checkups. Most interviewees reported that nothing had specifically triggered the issue.
Nineteen interviewees stated that their GP had originally taken the initiative and raised the issue of obesity, while 17 others raised the subject with their GP themselves.
Twenty-three interviewees reported that weight counselling has only been taken place once, 13 interviewees reported weight counselling more than once. Most (26) stated that their weight situation came up in discussion rather irregularly.
GPs pointed out the negative impact of obesity in almost every case (33). After determining the excess weight, some (16) looked for possible causes to respond more effectively to individual needs.
Most (27) stated that their GP recommended moderate weight reduction towards maintaining their new weight based on the doctor-patient agreement to lose weight. However, only three reported any agreement on specific targets.
Thirty-one interviewees reported receiving dietary counselling. GPs often recommended a low-calorie diet and gave specific advice on which foods to avoid or replace. Other patients were advised to reduce their food intake and change their eating culture. The GP handed out a diet plan in three cases. Four interviewees stated that the GP recommended an app specifically for diet adjustment. Seven interviewees were referred to support services.
Diet was discussed relatively often, but only a small proportion of those interviewed remembered receiving exercise counselling. Apart from general references to the importance of regular exercise, ten interviewees described exercise suggestions.
|Table 1: Sample sociodemographics (N = 36).|
|Telephone interview / chat option||31 / 5|
|Age||Average 47 years old (median)|
|Gender||20 female, 16 male|
|BMI||Average 28 kg/m2, 14 >30 kg/m2; range: 8.5|
|Living environment||16 in a large city or town, 20 in a small town or rural area|
Satisfaction with counselling
Most interviewees (25) appreciated their GP signalling a general willingness to help, pointing out the risk factors of being overweight and responding to questions. However, many criticised the actual consultation that their GP provided. One particular point of criticism was the lack of continuous support.
Another widespread point of criticism raised by interviewees that had received suggestions of specific weight-loss measures from their GP was the lack of any way of measuring their achievement. The patients lacked any form of benchmark or source of motivation beyond general recommendations.
Twelve interviewees had been successful in losing weight sustainably and visibly over recent years or months according to their own account. Six interviewees attributed this to support from their GP. Twenty-one interviewees stated that they had felt a lack of therapeutic support.
In addition, most of those interviewed (24) reported that their GP did not refer them enough to assistance and support services for continuous weight loss or increased fitness in the local area during consultation.
“I felt frustrated. ‘Just do a course.’ Ok, which one then?” (I-20m)
Ten interviewees mentioned that they occasionally felt a lack of empathy from GPs in dealing with their weight issues. They reported on situations clearly revealing insensitive, condescending or insulting behaviour.
Sixteen interviewees described passivity on the part of their GP leading to patients feeling abandoned with their weight problem.
Regardless of the care experienced, most of the interviewees favoured an active approach by GPs in dealing with overweight patients, advocating a frank but polite and sensitive approach.
Continuous counselling with ongoing advice and, importantly, motivation played a key role for most interviewees. Interviewees saw great importance in agreeing on specific targets and measures to achieve them. The individual steps should be set to match the sensitivities and interests of the patients.
“I’d like to see a diet or exercise programme so I can slowly but surely lose weight.” (I-19f)
Interviewees articulated a desire for referrals to support services, whether in the form of health insurance services, gym classes or self-help groups.
Obese patients see potential in general practice to respond appropriately and consistently to the individual needs of each patient. These prerequisites led to a significant proportion of interviewees sensing an increased willingness to lose weight if their GP took an active role in counselling [11, 24].
Nevertheless, overweight problems were often discovered incidentally or only raised after a delay. Apart from that, many patients complained about the lack of any regular exchange of information on their weight situation and that GPs often only kept to a general advice on diet and/or exercise. Interviewees saw the lack of specific agreement on weight-loss targets as a major deficit. In addition, overweight patients only received referrals to existing support services on an ad hoc basis.
Strengths and weaknesses
Our type of recruitment provided an effective way of attracting patients willing to speak as openly as possible about overweight and obesity management provided by GPs.
This is a non-representative study on a small sample which is not representative of all severely overweight patients in general practice. Online recruitment from web forums leads to the risk of only a certain group of interviewees being enrolled into the sample.
We held more than a third of the interviews by online chat rather than phone.
Comparison to existing studies
The results agree with the general findings situation indicating that obesity is a polarising disorder amongst doctors [6, 8, 9, 19, 21, 32]. Previous studies have already noted that GPs often avoid taking an active role in obesity management [18, 30, 33]. Another important point is that many GPs feel abandoned in a role for comprehensive and long-term obesity management. Studies have shown GPs complaining about a deficit in existing structures leading to a lack of individualised therapy concepts for patients [13, 19, 25, 27, 34]. Awareness of support services for patient referral is often limited .
Recent studies have emphasised the immense value and indispensable role of general practice in managing weight issues towards effectively counteracting the global spread of overweight and obesity [35, 36].
In general practice, diagnosing severe overweight or obesity should be combined with specific action recommendations and realistic weight-loss targets [37, 38]. Diet and exercise counselling would seem to make a sensible contribution towards reinforcing obesity prevention [39, 40]. Regular counselling sessions with a strategy of engaging with patients in their personal situation together with continuous patient motivation are important prerequisites for the long-term success [37, 41, 42].
GPs should also be encouraged in their role as mediators by referring obesity patients to an extended healthcare network, as necessary . Local health promotion networks could provide a high level of additional value in providing GPs with an overview of existing health services for referring patients to the services they need . Developing structured primary care programmes for obesity management would seem sensible.
The interviews have shown that obese patients see GPs as the main point of contact for support and therapy. Even with the favourable conditions of general practice, the interviews have indicated that the potential of GPs is currently not being fully exploited in overweight and obesity management. GPs should therefore be encouraged to address obesity promptly and consistently.
No financial support and no other potential conflict of interest relevant to this article were reported.
Dr. phil. Julian Wangler
Centre for General Medicine and Geriatrics
Am Pulverturm 13
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