Primary care providers' communication with patients during weight counseling: a focus group study

Communication about weight-related issues with adult patients with obesity in general practice: A scoping review

Background

Primary care providers see patients with obesity in general practice every day but may be challenged regarding communication about obesity. The research question of this study is: how do general practitioners and general practice staff and adult patients with obesity communicate about weight-related issues?

Methods

A scoping review approach was used, searching PubMed, Scopus and CINAHL for peer-reviewed studies - of both quantitative and/or qualitative study designs, and published between 2001 and 2021.

Results

Twenty articles were included. The weight-related issues discussed were by far physical issues, and only one study mentioned psychosocial issues. Most of the included studies contained information on who initiates the communication, how the weight-related issues are addressed and handled, and also obstacles and challenges in relation to the communication. The studies lacked information of when the weight-related issues are addressed and differences in views and experiences when discussing weight-related issues in general practice.

Conclusion

Studies with the main focus communication about obesity and overall health in general practice are needed. Findings also indicate, that non-stigmatizing communication tools and guidelines are needed on this area to promote these types of conservations.

Weight Communication: How Do Health Professionals Communicate about Weight with Their Patients in Primary Care Settings?

This study aimed to investigate how health professionals (HPs) communicate about weight with their patients. Semi-structured interviews were conducted with 33 health professionals (7 family physicians, 13 nurse practitioners, and 13 dietitians) working in multidisciplinary healthcare settings in Canada. Thematic analysis revealed four main approaches used by HPs to communicate about weight: 1) Analyzing patient perspectives, 2) focusing on overall health rather than weight, 3) directly addressing the topic, and 4) avoiding the topic. The approach chosen was influenced by HPs' outlook on obesity; for example, those who believed obesity to be a chronic disease did not hesitate to communicate about weight. However, some HPs who reported having obesity mentioned avoiding the topic of weight with their patients and emphasized the importance of establishing a trusting relationship with patients before addressing the topic. The approach chosen by HPs also seemed to be influenced by patient receptiveness, level of readiness, and motivation. Weight communication can be sensitive and the approach used to begin the topic of weight may differ based on patient- and HP factors. Future clinical practice guidelines may benefit from shifting toward communicating about modifiable risk factors rather than weight.

A systematic review and thematic synthesis of qualitative studies exploring GPs' and nurses' perspectives on discussing weight with patients with overweight and obesity in primary care

Guidelines and evidence suggest primary care clinicians should give opportunistic interventions to motivate weight loss, but these rarely occur in practice. We sought to examine why by systematically reviewing qualitative research examining general practitioners' ('GPs') and nurses' views of discussing weight with patients. We systematically searched English language publications (1945-2018) to identify qualitative interview and focus group studies. Thematic methods were used to synthesise the findings from these papers. We synthesised the studies by identifying second-order themes (explanations offered by the original researchers) and third-order constructs (new explanations which went beyond those in the original publications). Quality assessment using the Joanna Briggs checklist was undertaken. We identified 29 studies (>601 GPs, nurses and GP trainees) reporting views on discussing weight with patients. Key second-order themes were lack of confidence in treatments and patients' ability to make changes, stigma, interactional difficulty of discussing the topic and a belief of a wider societal responsibility needed to deal with patients with overweight and obesity. The third-order analytical theme was that discussions about weight were not a priority, and other behavioural interventions, including those relating to smoking, often took precedent. GPs and nurses reported that noting body mass index measurements at every consultation alongside a framework to deliver interventions would likely increase the frequency and perceived efficacy of behavioural weight interventions. GPs and nurses acknowledge the importance of obesity as a health issue, but this is insufficient, particularly amongst GPs, for them to construe this as a medical problem to address with patients in consultations. Strategies to implement clinical guidelines need to make tackling obesity a clinical priority. Training to overcome interactional difficulties, regular weighing of patients and changing expectations and understanding of weight loss interventions are also probably required.

Physicians certified by the American Board of Obesity Medicine provide evidence-based care

Our objective was to determine the clinical services offered by American Board of Obesity Medicine (ABOM) Diplomates and whether guideline concordant services varied by clinical practice attributes. We conducted a cross-sectional analysis of the 2019 ABOM Diplomate survey (response rate 19.2%). Respondents (n = 494) self-reported services offered: nutrition, exercise, mental health, minimally invasive bariatric procedures, perioperative bariatric surgical care and FDA-approved anti-obesity medications. We graded concordance of services offered with three evidence-based obesity guidelines, and then conducted bivariate analyses comparing concordance by practice attributes. Most responding ABOM Diplomates offered nutrition (90.1%), exercise (67.8%) and mental health (76.7%). Few offered minimally invasive procedures (24.3%), and most provided perioperative surgical care (63.0%). Most (83.4%) prescribed FDA-approved medications-typically both short- and long-term agents (70.9%). Few Diplomates had low concordance with the American Heart Association/American College of Cardiology/The Obesity Society (AHA/ACC/TOS) guidelines (24.7%). Those who managed more obesity-related conditions and endorsed AHA/ACC/TOS guideline use had higher concordance with these recommendations. No differences in guideline concordance existed by population, clinical effort or location. We found similar findings regarding concordance with ) American Association of Clinical Endocrinologists/American College of Endocrinology and Obesity Medicine Association guidelines. In conclusion, most responding ABOM Diplomates offer evidence-based obesity medicine services. Clinicians may therefore have increased confidence in patient receipt of evidence-based care when referring to an ABOM Diplomate.

Preoperative communication between anaesthetists and patients with obesity regarding perioperative risks and weight management: a structured narrative review

BACKGROUND

Individuals with obesity frequently present for anaesthesia and surgery. Good communication during the preoperative consultation can optimise the provision of relevant health information and guide improvement of health status preoperatively.

METHODS

We planned a systematic literature review to assess existing guidelines and evidence of effectiveness for how anaesthetists should communicate with patients who have obesity in the preoperative period about perioperative risks and weight management. Database searches used keywords related to perioperative weight loss conversations. We found no papers that directly addressed our aim. The literature identified as most relevant was analysed in the form of a narrative review.

RESULTS

The majority of suggestions for weight loss conversations came from primary care. Four primary themes potentially relevant to anaesthetists were identified: barriers to such conversations, communication tools, language and communication and specific recommendations. Identified barriers included lack of skills, training, poor remuneration, pessimism and time constraints for clinicians. Established discussion tools including the '5A's' approach (Assess, Advise, Agree, Assist, Arrange) and motivational interviewing may hold promise to improve preoperative conversations. The papers highlighted a need for empathetic language, including use of patient-specific language where possible.

CONCLUSIONS

There are currently no published guidelines for how anaesthetists could most effectively discuss weight in the perioperative period with patients who have obesity. Much of the literature for obesity communication is based on the primary care setting. The perioperative period may represent an increased time of receptiveness for patients. Guidelines for discussions about weight management and associated perioperative risk are suggested.

Exploring Physical Therapist Adherence to Clinical Guidelines When Treating Patients With Knee Osteoarthritis in Australia: A Mixed Methods Study

OBJECTIVE

The authors aimed to understand how physical therapists used practice guidelines to manage patients with knee osteoarthritis (OA) in Australia.

METHODS

This study used a concurrent triangulation mixed-method approach to explore how physical therapists applied clinical guidelines when managing patients with knee OA in an outpatient setting via completion of a semi-structured interview. Interviews were thematically analyzed by 2 investigators using an inductive approach. Themes were then triangulated to the results of an audit that evaluated the level of adherence to respective areas in the clinical guidelines among physical therapists at the participating site.

RESULTS

One main theme and 3 subthemes were identified from 18 participants: (1) physical therapists were most confident in applying guidelines to improving range of movement and strength; (2) lack of knowledge in prescription of aerobic exercise, weight, and pain management; (3) pain is a bigger barrier in areas where knowledge is lacking; and (4) lack of clarity around the scope of practice. Themes converged with the reported level of adherence to guidelines.

CONCLUSIONS

Physical therapists commonly include range of movement and muscle strength exercises when managing people with knee OA. However, they were less confident in prescribing aerobic exercise and recommending weight and pain management strategies.

IMPACT

Apart from the need to upskill physical therapists in the aforementioned areas of clinical practice, the role of a physical therapist in the management of people with knee OA requires further clarification.

Role of Commercial Weight-Loss Programs in Medical Management of Obesity

Rates of obesity counseling are low among physicians because of the lack of time and training in this area. In recognition of this challenge, recent national guidelines encourage physicians to refer patients with obesity to intensive, comprehensive lifestyle programs to lose weight. Some commercial weight-loss programs meet these criteria, and this article reviews the evidence from randomized controlled trials regarding such programs' weight-loss efficacy and safety as well as glycemic outcomes among patients with and without diabetes mellitus. A discussion of how physicians might approach the referral process and continued management of patients participating in these programs is included.

The importance of language in engagement between health-care professionals and people living with obesity: a joint consensus statement

Obesity is a chronic condition that requires long-term management and is associated with unprecedented stigma in different settings, including during interactions with the health-care system. This stigma has a negative effect on the mental and physical health of people with obesity and can lead to avoidance of health care and disruption of the doctor-patient relationship. Considerable evidence exists to suggest that simply having a conversation about obesity can lead to weight loss, which translates into health benefits. However, both health-care practitioners and people living with obesity report apprehension in initiating this conversation. We have collaborated with stakeholders from Obesity UK, physicians, dieticians, clinical psychologists, obesity researchers, conversation analysts, nurses, and representatives from National Health Service England Diabetes and Obesity. This group has contributed to the production of this consensus statement, which addresses how people living with obesity wish to have their condition referred to and provides practical guidance for health-care professionals to facilitate collaborative and supportive discussions about obesity. Expert stakeholders consider that changes to language used at the point of care can alleviate the stigma of obesity within the health-care system and support improved outcomes for both people living with obesity and for the health-care system.

Transforming Health Experience and Action through Shifting the Narrative on Obesity in Primary Care Encounters

We sought to understand the impact of primary care conversations about obesity on people's everyday life health experience and practices. Using a dialogic narrative perspective, we examined key moments in three very different clinical encounters, the patients' journals, and follow-up interviews over several weeks. We trace how people living with obesity negotiate narrative alternatives that are offered during clinical dialogue to transform their own narrative and experience of obesity and self. Findings provide pragmatic insights into how providers can play a significant role in shifting narratives about obesity and self and how such co-constructed narratives translate into change and tangible health outcomes in people's lives.

Geographic Availability of Physicians Certified by the American Board of Obesity Medicine Relative to Obesity Prevalence

OBJECTIVE

The objective of this study is to determine the distribution of adult and pediatric American Board of Obesity Medicine (ABOM) diplomates relative to the prevalence of obesity by US state.

METHODS

Data from the ABOM physician directory were used to determine original specialty and US state. Physicians were labeled as "adult medicine" physicians (i.e., internal medicine, family medicine, or internal medicine and pediatrics), "pediatric medicine" physicians (i.e., pediatrics, family medicine, or internal medicine and pediatrics), and "other physicians" (i.e., surgical specialty, other specialty, or unknown). Prevalence of obesity by state, according to the Centers for Disease Control and Prevention, was used for adults and adolescents in 2017 and for children in 2014. Counts of ABOM-certified adult medicine physicians and pediatric medicine physicians were conducted relative to obesity prevalence by state.

RESULTS

A total of 2,577 US-based ABOM-certified physicians were included (79% from adult medicine, 38% from pediatric medicine, and 15% from other fields). All US states had more than one ABOM-certified adult medicine physician, although geographic disparities existed in physician availability relative to obesity prevalence. Fewer pediatric medicine ABOM diplomates were available in all states.

CONCLUSIONS

Promotion of ABOM training and certification in certain geographic locations and among pediatric physicians may help address disparities in ABOM diplomate availability relative to obesity burden.

Acceptability and feasibility of weight management programmes for adults with severe obesity: a qualitative systematic review

OBJECTIVES

To improve our understanding of the acceptability of behavioural weight management programmes (WMPs) for adults with severe obesity.

DESIGN

A systematic review of qualitative evidence.

DATA SOURCES

Medline, Embase, PsycINFO, CINAHL, SCI, SSCI and CAB abstracts were searched from 1964 to May 2017.

ELIGIBILITY CRITERIA

Papers that contained qualitative data from adults with body mass index (BMI) ≥35 kg/m² (and/or the views of providers involved in their care) and considered issues about weight management.

DATA EXTRACTION AND SYNTHESIS

Two reviewers read and systematically extracted data from the included papers which were compared, and contrasted according to emerging issues and themes. Papers were appraised for methodological rigour and theoretical relevance using Toye's proposed criteria for quality in relation to meta-ethnography.

RESULTS

33 papers met our inclusion criteria from seven countries published 2007-2017. Findings were presented from a total of 644 participants and 153 programme providers. Participants described being attracted to programmes that were perceived to be novel or exciting, as well as being endorsed by their healthcare provider. The sense of belonging to a group who shared similar issues, and who had similar physiques and personalities, was particularly important and seemed to foster a strong group identity and related accountability. Group-based activities were enjoyed by many and participants preferred WMPs with more intensive support. However, some described struggling with physical activities (due to a range of physical comorbidities) and not everyone enjoyed group interaction with others (sometimes due to various mental health comorbidities). Although the mean BMI reported across the papers ranged from 36.8 to 44.7 kg/m², no quotes from participants in any of the included papers were linked to specific detail regarding BMI status.

CONCLUSIONS

Although group-based interventions were favoured, people with severe obesity might be especially vulnerable to physical and mental comorbidities which could inhibit engagement with certain intervention components.

Communication between patients and primary care physicians after behavioural weight loss: an observational study

Primary care physicians can play a key role in supporting patients after behavioural weight loss, though little is known about communication between patients and physicians during this time. Adults (n=139) in a behavioural weight loss trial (delivered outside of primary care) who attended a primary care appointment after an initial weight loss period were surveyed to assess weight-related communication at their most recent appointment. Most participants (78%) reported discussing weight with their physician. Participants who discussed weight, compared to those who did not, lost more weight, had higher blood pressure, and were more likely to be male. Most (89%) reported that their physician was supportive of their weight loss, but only a few participants (6.9%) reported that their physician gave feedback on medical parameters. Areas for improvement identified include physicians providing universal support for modest weight changes and providing interpretation of medical measurements that changed due to weight loss.

Cardiovascular risk assessments at occupational health services: employee experiences

BACKGROUND

Across England in the UK, population screening for cardiovascular disease (CVD) primarily takes place within general practice in the form of the National Health Service Health Check. Additional screening sites such as occupational health are advocated to improve the population impact.

AIMS

To investigate participant experiences with cardiovascular and type 2 diabetes risk assessment (RA) at occupational health and subsequent support-seeking at general practice.

METHODS

Face-to-face interviews were conducted for this qualitative study. Participants were recruited at three workplaces; a steel works and two hospital sites. Using interpretive phenomenological analyses, themes were drawn from salient narratives and categorically organized.

RESULTS

There were 29 participants. Themes (n = 16) were organized into two domains; factors that facilitated (n = 9) or thwarted (n = 7) participant engagement with the RA and general practice. All participants described the RA as worthwhile and strongly valued RA at occupational health. Those with obesity and high CVD risk highlighted their difficulties in making lifestyle changes. Participants reported confusion and anxiety when GP advice about medication appeared to contradict what participants had interpreted during RA at occupational health.

CONCLUSIONS

This study highlights factors that facilitate or thwart engagement in cardiovascular RA at occupational health services and general practice follow-up. Stakeholders can integrate these factors into standard operating procedures to enhance participant engagement and enable safeguards that minimize potential harm to participants.

Mobile Health Technology in Prenatal Care: Understanding OBGYN Providers' Beliefs about Using Technology to Manage Gestational Weight Gain

OBJECTIVES

High gestational weight gain (GWG) is linked to adverse maternal/infant outcomes. Scant research has examined OB/GYN providers': 1) beliefs and barriers to using mobile health (mHealth) technology and 2) their perceptions of patient beliefs/barriers for using mHealth technology for managing GWG.

METHODS

Semi-structured interviews and focus groups with OB/GYN providers (N = 25) were conducted in person and via telephone. Principles of thematic analysis were used to content analyze the interviews; sample size was determined via data saturation.

RESULTS

Most providers didn't use technology when providing prenatal care (94%), recommended public websites for patients to obtain health information (72%), and reported a smartphone/tablet as the ideal tool for clinical care (83%). Providers also believed mHealth tools would be beneficial for high risk patients (e.g., overweight/obese; 67%). For the use of mHealth tools in clinical care, the most salient provider barriers were lack of time (78%), costs (61%), facility/technology issues (56%), and lack of provider willingness to adapt to change (44%). The most important provider-perceived patient barriers were access (72%) and lack of interest (67%).

CONCLUSIONS FOR PRACTICE

These findings suggest some OB/GYN providers may be open to using mHealth technology in prenatal clinics to help their patients manage GWG if the technology is time efficient and both providers and patients can overcome barriers. The success of incorporating mHealth technology for diet/exercise counseling in prenatal clinics will lie in making it time efficient and interesting for the patient. Novel strategies to overcome provider and patient barriers are essential.

Practice patterns of nurse practitioners related to weight management in primary care

BACKGROUND AND OBJECTIVES

Obesity prevalence rates for adults are at an all-time high. This systematic review of the literature aimed to examine the practice patterns of nurse practitioners (NPs) related to weight management in primary care and recommend future areas of research as it relates to the diagnosis and management of patients with obesity by NPs.

DATA SOURCES

The databases CINAHL PLUS with Full Text, Cochrane Central Register of Controlled Trials, ERIC, MEDLINE, PsycINFO, and SPORTDiscuss were searched.

CONCLUSIONS

The initial search resulted in 169 articles. Fifteen peer-reviewed articles from 13 studies were included in the analysis. Four themes emerged from the analysis: approach to practice; the practitioner's role within the interdisciplinary team; communication; and resources and tools.

IMPLICATIONS FOR PRACTICE

This review was conducted to better understand the challenges and facilitators to the management of patients with obesity in primary care. Future research between NPs and variables related to obesity are necessary to further identify areas for education, training, and policy development.

Bariatric surgery, lifestyle interventions and orlistat for severe obesity: the REBALANCE mixed-methods systematic review and economic evaluation

BACKGROUND

Adults with severe obesity [body mass index (BMI) of ≥ 35 kg/m2] have an increased risk of comorbidities and psychological, social and economic consequences.

OBJECTIVES

Systematically review bariatric surgery, weight-management programmes (WMPs) and orlistat pharmacotherapy for adults with severe obesity, and evaluate the feasibility, acceptability, clinical effectiveness and cost-effectiveness of treatment.

DATA SOURCES

Electronic databases including MEDLINE, EMBASE, PsycINFO, the Cochrane Central Register of Controlled Trials and the NHS Economic Evaluation Database were searched (last searched in May 2017).

REVIEW METHODS

Four systematic reviews evaluated clinical effectiveness, cost-effectiveness and qualitative evidence for adults with a BMI of ≥ 35 kg/m2. Data from meta-analyses populated a microsimulation model predicting costs, outcomes and cost-effectiveness of Roux-en-Y gastric bypass (RYGB) surgery and the most effective lifestyle WMPs over a 30-year time horizon from a NHS perspective, compared with current UK population obesity trends. Interventions were cost-effective if the additional cost of achieving a quality-adjusted life-year is < £20,000-30,000.

RESULTS

A total of 131 randomised controlled trials (RCTs), 26 UK studies, 33 qualitative studies and 46 cost-effectiveness studies were included. From RCTs, RYGB produced the greatest long-term weight change [-20.23 kg, 95% confidence interval (CI) -23.75 to -16.71 kg, at 60 months]. WMPs with very low-calorie diets (VLCDs) produced the greatest weight loss at 12 months compared with no WMPs. Adding a VLCD to a WMP gave an additional mean weight change of -4.41 kg (95% CI -5.93 to -2.88 kg) at 12 months. The intensive Look AHEAD WMP produced mean long-term weight loss of 6% in people with type 2 diabetes mellitus (at a median of 9.6 years). The microsimulation model found that WMPs were generally cost-effective compared with population obesity trends. Long-term WMP weight regain was very uncertain, apart from Look AHEAD. The addition of a VLCD to a WMP was not cost-effective compared with a WMP alone. RYGB was cost-effective compared with no surgery and WMPs, but the model did not replicate long-term cost savings found in previous studies. Qualitative data suggested that participants could be attracted to take part in WMPs through endorsement by their health-care provider or through perceiving innovative activities, with WMPs being delivered to groups. Features improving long-term weight loss included having group support, additional behavioural support, a physical activity programme to attend, a prescribed calorie diet or a calorie deficit.

LIMITATIONS

Reviewed studies often lacked generalisability to UK settings in terms of participants and resources for implementation, and usually lacked long-term follow-up (particularly for complications for surgery), leading to unrealistic weight regain assumptions. The views of potential and actual users of services were rarely reported to contribute to service design. This study may have failed to identify unpublished UK evaluations. Dual, blinded numerical data extraction was not undertaken.

CONCLUSIONS

Roux-en-Y gastric bypass was costly to deliver, but it was the most cost-effective intervention. Adding a VLCD to a WMP was not cost-effective compared with a WMP alone. Most WMPs were cost-effective compared with current population obesity trends.

FUTURE WORK

Improved reporting of WMPs is needed to allow replication, translation and further research. Qualitative research is needed with adults who are potential users of, or who fail to engage with or drop out from, WMPs. RCTs and economic evaluations in UK settings (e.g. Tier 3, commercial programmes or primary care) should evaluate VLCDs with long-term follow-up (≥ 5 years). Decision models should incorporate relevant costs, disease states and evidence-based weight regain assumptions.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42016040190.

FUNDING

The National Institute for Health Research Health Technology Assessment programme. The Health Services Research Unit and Health Economics Research Unit are core funded by the Chief Scientist Office of the Scottish Government Health and Social Care Directorate.

Randomised controlled trial and economic analysis of an internet-based weight management programme: POWeR+ (Positive Online Weight Reduction)

BACKGROUND

Behavioural counselling with intensive follow-up for obesity is effective, but in resource-constrained primary care settings briefer approaches are needed.

OBJECTIVES

To estimate the clinical effectiveness and cost-effectiveness of an internet-based behavioural intervention with regular face-to-face or remote support in primary care, compared with brief advice.

DESIGN

Individually randomised three-arm parallel trial with health economic evaluation and nested qualitative interviews.

SETTING

Primary care general practices in the UK.

PARTICIPANTS

Patients with a body mass index of ≥ 30 kg/m² (or ≥ 28 kg/m² with risk factors) identified from general practice records, recruited by postal invitation.

INTERVENTIONS

Positive Online Weight Reduction (POWeR+) is a 24-session, web-based weight management intervention completed over 6 months. Following online registration, the website randomly allocated participants using computer-generated random numbers to (1) the control intervention (n = 279), which had previously been demonstrated to be clinically effective (brief web-based information that minimised pressure to cut down foods, instead encouraging swaps to healthier choices and increasing fruit and vegetables, plus 6-monthly nurse weighing); (2) POWeR+F (n = 269), POWeR+ supplemented by face-to-face nurse support (up to seven contacts); or (3) POWeR+R (n = 270), POWeR+ supplemented by remote nurse support (up to five e-mails or brief telephone calls).

MAIN OUTCOME MEASURES

The primary outcome was a modelled estimate of average weight reduction over 12 months, assessed blind to group where possible, using multiple imputation for missing data. The secondary outcome was the number of participants maintaining a 5% weight reduction at 12 months.

RESULTS

A total of 818 eligible individuals were randomised using computer-generated random numbers. Weight change, averaged over 12 months, was documented in 666 out of 818 participants (81%; control, n = 227; POWeR+F, n = 221; POWeR+R, n = 218). The control group maintained nearly 3 kg of weight loss per person (mean weight per person: baseline, 104.4 kg; 6 months, 101.9 kg; 12 months, 101.7 kg). Compared with the control group, the estimated additional weight reduction with POWeR+F was 1.5 kg [95% confidence interval (CI) 0.6 to 2.4 kg; p = 0.001] and with POWeR+R was 1.3 kg (95% CI 0.34 to 2.2 kg; p = 0.007). By 12 months the mean weight loss was not statistically significantly different between groups, but 20.8% of control participants, 29.2% of POWeR+F participants (risk ratio 1.56, 95% CI 0.96 to 2.51; p = 0.070) and 32.4% of POWeR+R participants (risk ratio 1.82, 95% CI 1.31 to 2.74; p = 0.004) maintained a clinically significant 5% weight reduction. The POWeR+R group had fewer individuals who reported doing another activity to help lose weight [control, 47.1% (64/136); POWeR+F, 37.2% (51/137); POWeR+R, 26.7% (40/150)]. The incremental cost to the health service per kilogram weight lost, compared with the control group, was £18 (95% CI -£129 to £195) for POWeR+F and -£25 (95% CI -£268 to £157) for POWeR+R. The probability of being cost-effective at a threshold of £100 per kilogram was 88% and 98% for POWeR+F and POWeR+R, respectively. POWeR+R was dominant compared with the control group. No harms were reported and participants using POWeR+ felt more enabled in managing their weight. The qualitative studies documented that POWeR+ was viewed positively by patients and that health-care professionals generally enjoyed supporting patients using POWeR+.

STUDY LIMITATIONS

Maintenance of weight loss after 1 year is unknown.

FUTURE WORK

Identifying strategies for longer-term engagement, impact in community settings and increasing physical activity.

CONCLUSION

Clinically valuable weight loss (> 5%) is maintained in 20% of individuals using novel written materials with brief follow-up. A web-based behavioural programme and brief support results in greater mean weight loss and 10% more participants maintain valuable weight loss; it achieves greater enablement and fewer participants undertaking other weight-loss activities; and it is likely to be cost-effective.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN21244703.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 21, No. 4. See the NIHR Journals Library website for further project information.

Providing online weight management in Primary Care: a mixed methods process evaluation of healthcare practitioners' experiences of using and supporting patients using POWeR

BACKGROUND

An online weight management intervention (POWeR+) combined with a small amount of primary care healthcare practitioner support is effective in helping patients to lose weight, but little is known about how practitioners interact with the POWeR+ intervention or their experiences of providing support for patients using POWeR+. The aim of this study was to explore practitioners' usage of POWeR+ and their experiences of providing support to patients using POWeR+.

METHODS

Set within a randomised controlled trial of POWeR+, practitioners' usage of POWeR+ was automatically captured and a qualitative process analysis was conducted employing semi-structured telephone interviews with practitioners who provided support to patients using POWeR+. The usage analysis captured how 54 practitioners used the POWeR+ intervention. Thirteen telephone interviews explored practitioners' experiences of using POWeR+ and providing patients with face-to-face or remote (email and telephone) support. Interview data were analysed using inductive thematic analysis.

RESULTS

Usage analysis indicated that almost all practitioners engaged with POWeR+. Pages which displayed patients' progress and allowed practitioners to email patients were used the most. Practitioners found POWeR+ straightforward and easy to use. Some practitioners preferred providing support face-to-face, which they enjoyed more than remote support. A small number of nurses found providing non-directive support using the CARe approach (Congratulate, Ask, Remind) challenging, feeling it was the opposite of their normal approach. POWeR+ enabled practitioners to raise the topic of weight loss with patients, and POWeR+ was viewed as a superior alternative to existing weight management support which was limited in most practices. Still some practitioners found it difficult to fit providing support into their busy schedules.

CONCLUSIONS

Overall, practitioners engaged well with POWeR+ and perceived providing patients with support whilst using POWeR+ as acceptable and feasible. CARe provides a potentially useful model for how practitioners can combine human and digital support in a cost-effective way, which could be useful for the management of other conditions. Some potential barriers to implementation were identified, which allowed modification of POWeR+. The findings suggest that implementing this cost-effective online weight management intervention in Primary Care would be feasible and acceptable to practitioners.

TRIAL REGISTRATION

ClinicalTrial.gov, ISRCTN21244703.

Physicians' views and experiences of discussing weight management within routine clinical consultations: A thematic synthesis

OBJECTIVE

To systematically search and synthesise qualitative studies of physicians' views and experiences of discussing weight management within a routine consultation.

METHODS

A systematic search of four electronic databases identified 11,169 articles of which 16 studies met inclusion criteria. Quality was appraised using the Critical Appraisal Skills Programme tool and a thematic synthesis conducted of extracted data.

RESULTS

Four analytical themes were found: (1) physicians' pessimism about patients' weight loss success (2) physicians' feel hopeless and frustrated (3) the dual nature of the physician-patient relationship (4) who should take responsibility for weight management.

CONCLUSION

Despite clinical recommendations barriers remain during consultations between physicians and patients about weight management. Many of these barriers are potentially modifiable.

PRACTICE IMPLICATIONS

Improving training, providing clearer guidelines and placing a greater emphasis on collaboration within and between clinicians will help reduce barriers for both physicians and patients. In particular, there is an urgent need for more specialised training for physicians about weight management to promote knowledge and skills in behaviour change techniques and ways to broach sensitive topics without damaging patient relationships.

Dietary and Behavioral Approaches in the Management of Obesity

Given the prevalence of overweight and obesity and their associated health conditions, clinicians will be increasingly tasked with the responsibility of addressing overweight and obesity. This article reviews the 5As approach-assess, advise, agree, assist, arrange-and how clinicians can use the approach facilitate weight management discussions with their patients that met the recommendations provided in the 2013 adult weight management guidelines issued by the American Heart Association/American College of Cardiology/The Obesity Society.

'I should have taken that further' - missed opportunities during cardiovascular risk assessment in patients with psoriasis in UK primary care settings: a mixed-methods study

BACKGROUND

Unhealthy lifestyle is common in psoriasis, contributing to worsening disease and increased cardiovascular disease (CVD) risk. CVD risk communication should improve patients' understanding of risk and risk-reducing behaviours; however, the effectiveness of risk screening is debated and evaluation currently limited.

OBJECTIVE

To examine the process of assessing for and communicating about CVD risk in the context of psoriasis.

DESIGN

Mixed-methods study in English general practices to (i) determine proportions of CVD risk factors among patients with psoriasis at risk assessment and (ii) examine patient and practitioner experiences of risk communication to identify salient 'process' issues. Audio recordings of consultations informed in-depth interviews with patients and practitioners using tape-assisted recall, analysed with framework analysis.

PARTICIPANTS

Patients with psoriasis (n = 287) undergoing CVD risk assessment; 29 patients and 12 practitioners interviewed.

RESULTS

A high proportion of patients had risk factor levels apparent at risk assessment above NICE recommendations: very high waist circumference (52%), obesity (35%), raised blood pressure (29%), smoking (18%) and excess alcohol consumption (18%). There was little evidence of personalized discussion about CVD risk and behaviour change support in consultations. Professionals reported a lack of training in behaviour change, while patients wanted to discuss CVD risk/risk reduction and believed practitioners to be influential in supporting lifestyle management.

CONCLUSIONS

Despite high levels of risk factors identified, opportunities may be missed in consultations to support patients with psoriasis to understand CVD risk/risk reduction. Practitioners need training in behaviour change techniques to capitalize on 'teachable moments' and increase the effectiveness of risk screening.

Racial and ethnic minority patients report different weight-related care experiences than non-Hispanic Whites

Our objective was to compare patients' health care experiences, related to their weight, across racial and ethnic groups. In Summer 2015, we distributed a written survey with telephone follow-up to a random sample of 5400 racially/ethnically and geographically diverse U.S. adult health plan members with overweight or obesity. The survey assessed members' perceptions of their weight-related healthcare experiences, including their perception of their primary care provider, and the type of weight management services they had been offered, or were interested in. We used multivariable multinomial logistic regression to examine the relationship between race/ethnicity and responses to questions about care experience. Overall, 2811 members (53%) responded to the survey and we included 2725 with complete data in the analysis. Mean age was 52.7 years (SD 15.0), with 61.7% female and 48.3% from minority racial/ethnic groups. Mean BMI was 37.1 kg/m² (SD 8.0). Most (68.2%) respondents reported having previous discussions of weight with their provider, but interest in such counseling varied by race/ethnicity. Non-Hispanic blacks were significantly less likely to frequently avoid care (for fear of discussing weight/being weighed) than whites (OR 0.49, 95% CI 0.26–0.90). Relative to whites, respondents of other race/ethnicities were more likely to want weight-related discussions with their providers. Race/ethnicity correlates with patients' perception of discussions of weight in healthcare encounters. Clinicians should capitalize on opportunities to discuss weight loss with high-risk minority patients who may desire these conversations.

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Minority patients may desire more information about weight management.

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Non-Hispanic whites may be more likely to avoid care due to fear of weight bias.

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Clinicians could conduct more sensitive weight loss discussions with all patients.

Perceived helpfulness of the individual components of a behavioural weight loss program: results from the Hopkins POWER Trial

Background

Behavioural weight loss programs are effective first‐line treatments for obesity and are recommended by the US Preventive Services Task Force. Gaining an understanding of intervention components that are found helpful by different demographic groups can improve tailoring of weight loss programs. This paper examined the perceived helpfulness of different weight loss program components.

Methods

Participants (n = 236) from the active intervention conditions of the Practice‐based Opportunities for Weight Reduction (POWER) Hopkins Trial rated the helpfulness of 15 different components of a multicomponent behavioural weight loss program at 24‐month follow‐up. These ratings were examined in relation to demographic variables, treatment arm and weight loss success.

Results

The components most frequently identified as helpful were individual telephone sessions (88%), tracking weight online (81%) and coach review of tracking (81%). The component least frequently rated as helpful was the primary care providers' general involvement (50%). Groups such as older adults, Blacks and those with lower education levels more frequently reported intervention components as helpful compared with their counterparts.

Discussion

Weight loss coaching delivered telephonically with web support was well received. Findings support the use of remote behavioural interventions for a wide variety of individuals.

Satisfaction with primary care provider involvement is associated with greater weight loss: Results from the practice-based POWER trial

OBJECTIVE

To evaluate the association between the patient-provider relationship, satisfaction with primary care provider's (PCP) involvement and weight loss in a practice-based weight loss trial.

METHODS

POWER was a practice-based randomized controlled behavioral weight loss trial. Participants completed questionnaires about patient-provider relationship and satisfaction with their PCPs' involvement in the trial. PCPs completed a demographics and practice survey. The main outcome was the mean weight change from baseline to 24 months. We created mixed-effect models, accounting for the random effects of patients clustering with the PCP and the repeated outcome assessments within patient over time, and adjusted for randomization assignment, age, gender, race and clinical site.

RESULTS

347 (of 415) were included. Mean age was 54.8 years, mean BMI was 36.3 kg/m(2). Participants reported high quality patient-provider relationships (mean summary score=29.1 [range 14-32]). Patient-provider relationship quality was not associated weight loss in either the intervention or control groups. Among intervention participants, higher ratings of the helpfulness of the PCPs' involvement was associated with greater weight loss (p=0.005).

CONCLUSION

Patient-provider relationship quality was not associated with weight loss in a practice-based weight loss trial but rating PCPs as helpful in the intervention was associated with weight loss.

PRACTICE IMPLICATIONS

Partnering with PCPs to deliver weight loss programs may promote greater participant satisfaction and weight loss.

Perceived judgment about weight can negatively influence weight loss: a cross-sectional study of overweight and obese patients

OBJECTIVE

To examine the association between patient-perceived judgments about weight by primary care providers (PCPs) and self-reported weight loss.

METHODS

We conducted a national internet-based survey of 600 adults engaged in primary care with a body mass index (BMI)≥25 kg/m(2) in 2012. Our weight loss outcomes included attempted weight loss and achieved ≥10% weight loss in the last 12 months. Our independent variable was "feeling judged about my weight by my PCP." We created an interaction between perceiving judgment and PCP discussing weight loss as an independent variable. We conducted a multivariate logistic regression model adjusted for patient and PCP factors using survey weights.

RESULTS

Overall, 21% perceived that their PCP judged them about their weight. Respondents who perceived judgment were significantly more likely to attempt weight loss [odds ratios (OR) 4.67, 95% confidence interval (CI) 1.96-11.14]. They were not more likely to achieve ≥10% weight loss [OR 0.87, 95%CI 0.42-1.76]. Among patients whose PCPs discussed weight loss, 20.1% achieved ≥10% weight loss if they did not perceive judgment by their PCP as compared to 13.5% who perceived judgment.

CONCLUSIONS

Weight loss discussions between patients and PCPs may lead to greater weight loss in relationships where patients do not perceive judgment about their weight.

Differences in the perceived role of the healthcare provider in delivering vascular health checks: a Q methodology study

BACKGROUND

The UK Department of Health introduced the National Health Service (NHS) Health Check Programme in April 2009 in an attempt to improve primary and secondary prevention of cardiovascular disease in the UK population and to reduce health inequalities. Healthcare professionals' attitudes towards giving lifestyle advice will influence how they interact with patients during consultations. We therefore sought to identify the attitudes of primary care healthcare professionals towards the delivery of lifestyle advice in the context of the NHS Health Check Programme.

METHODS

Fifty-two primary care healthcare professionals undertook a Q sort with 36 statements that represented a range of viewpoints about the importance of lifestyle change, medication, giving lifestyle advice in the primary care setting, and the individual, social and material factors that might impact on lifestyle related behaviour change. Sorts were analysed by-person using principal components analysis and varimax rotation.

RESULTS

Five statistically independent factors (accounts) reflected distinct views on the topic. Account 1 was supportive of initiatives like the NHS Health Check, and emphasised the importance of professionals working collaboratively with patients to facilitate lifestyle change. Account 2 expressed views on the potential overuse of statin medication and placed responsibility for lifestyle change with the patient. Account 3 viewed the healthcare professional role to be one of educator, emphasising the provision of information. Account 4 perceived lifestyle change to be difficult for patients and emphasised the need for healthcare professionals to be role models. Account 5 was inconsistent about the value of lifestyle change, or the role of healthcare professionals in promoting it, a finding that may be due to ambivalence about the health check or to lack of engagement with the Q sort task. We found no strong associations between any of the factors and, gender, role, age or ethnicity.

CONCLUSIONS

Our findings suggest that healthcare professionals hold viewpoints that may influence how they interact with patients during health checks. When implementing programmes like the NHS Health Check, it would be useful to take healthcare professionals' views into account. Attitudes and beliefs could be explored during training sessions, for example.