Decisions about weight management: a synthesis of qualitative studies of obesity

The development of a core outcomes set for self-management interventions for patients living with obesity

Self-management interventions (SMIs) can improve the life of patients living with obesity. However, there is variability in the outcomes used to assess the effectiveness of SMIs and these are often not relevant for patients. In the context of COMPAR-EU, our aim was to develop a core outcome set (COS) for the evaluation of SMIs for patients with obesity. We followed a four steps multimethod approach: (1) the development of the initial catalogue of outcomes; (2) a scoping review of reviews on patients' values and preferences on outcomes of self-management (SM); (3) a Delphi survey including patients and patient representatives to rate the importance of outcomes; and (4) a 2-day consensus workshop with patients, patient representatives, healthcare professionals and researchers. The initial catalogue included 82 outcomes. Ten patients and patient's representatives participated in the Delphi survey. We identified 16 themes through the thematic synthesis of the scoping review that informed 37.80% of the outcomes on initial catalogue. Five patients, five healthcare professionals, and four researchers participated in the consensus workshop. After the consensus process, 15 outcomes were selected to be part of the final COS, and five supplementary outcomes were also provided. We developed a COS for the evaluation of SMIs in obesity with a significant involvement of patients and other key stakeholders. This COS will help improving data synthesis and increasing the value of SM research data in healthcare decision making.

The Perspectives of Patients with Chronic Diseases and Their Caregivers on Self-Management Interventions: A Scoping Review of Reviews

BACKGROUND

Self-management (SM) interventions are supportive interventions systematically provided by healthcare professionals, peers, or laypersons to increase the skills and confidence of patients in their ability to manage chronic diseases. We had two objectives: (1) to summarise the preferences and experiences of patients and their caregivers (informal caregivers and healthcare professionals) with SM in four chronic diseases and (2) to identify and describe the relevant outcomes for SM interventions from these perspectives.

METHODS

We conducted a mixed-methods scoping review of reviews. We searched three databases until December 2020 for quantitative, qualitative, or mixed-methods reviews exploring patients' and caregivers' preferences or experiences with SM in type 2 diabetes mellitus (T2DM), obesity, chronic obstructive pulmonary disease (COPD), and heart failure (HF). Quantitative data were narratively synthesised, and qualitative data followed a three-step descriptive thematic synthesis. Identified themes were categorised into outcomes or modifiable factors of SM interventions.

RESULTS

We included 148 reviews covering T2DM (n = 53 [35.8%]), obesity (n = 20 [13.5%]), COPD (n = 32 [21.6%]), HF (n = 38 [25.7%]), and those with more than one disease (n = 5 [3.4%]). We identified 12 main themes. Eight described the process of SM (disease progression, SM behaviours, social support, interaction with healthcare professionals, access to healthcare, costs for patients, culturally defined roles and perceptions, and health knowledge), and four described their experiences with SM interventions (the perceived benefit of the intervention, individualised care, sense of community with peers, and usability of equipment). Most themes and subthemes were categorised as outcomes of SM interventions.

CONCLUSION

The process of SM shaped the perspectives of patients and their caregivers on SM interventions. Their perspectives were influenced by the perceived benefit of the intervention, the sense of community with peers, the intervention's usability, and the level of individualised care. Our findings can inform the selection of patient-important outcomes, decision-making processes, including the formulation of recommendations, and the design and implementation of SM interventions.

The Northumberland Exercise Referral Scheme as a Universal Community Weight Management Programme: A Mixed Methods Exploration of Outcomes, Expectations and Experiences across a Social Gradient

Exercise referral schemes (ERS) are internationally recognised, yet little attention has been paid to discrete referral groups or the influence of wider social determinants of health. The primary quantitative element of this mixed methods study used a mixed effects linear model to examine associations of sociodemographic predictors, obesity class and profession of referrer on weight and physical activity (PA) variables for weight-related referrals (n = 3624) to an established 24-week ERS. Chained equations modelling imputed missing data. The embedded qualitative element (n = 7) used individual semi-structured interviews to explore participant weight-related expectations and experiences. Age, gender and profession of referrer influenced weight loss. PA increased and was influenced by age and gender. The weight gap between the most and least obese narrowed over time but the PA gap between most and least widened. Age, employment and obesity class were most predictive of missing data but would unlikely alter overall conclusions. Qualitative themes were weight-loss support, personal circumstances and strategies, and weight expectations versus wellbeing rewards. This ERS worked, did not widen existing obesity inequalities, but demonstrated evidence of PA inequalities for those living with deprivation. To improve equity of experience, we recommend further stakeholder dialogue around referral experience and ongoing support needs.

Facing obesity: Adapting the collaborative deliberation model to deal with a complex long-term problem

OBJECTIVE

Care communication about obesity needs to respond to the complex biopsychosocial processes that affect weight and health. The collaborative deliberation model conceptualizes interpersonal work that underpins empathic communication and shared decision-making. The goal of this study was to elucidate how primary care practitioners can use the model to achieve shared obesity assessment and care planning.

METHODS

This qualitative study used direct observation of clinical encounters with twenty patients with obesity sampled for maximum variation in context, semi-structured patient and provider interviews, patient journals and two follow-up interviews over eight weeks. Themes were compared to the original model.

RESULTS

We identified five processes that may be relevant for collaborative deliberation about obesity in addition to the original model: (1) Exploring the story, (2) Reframing the story, (3) Co-constructing a new story, (4) Choosing a priority, and (5) Experimenting with alternatives.

CONCLUSIONS

We propose an enhanced collaborative deliberation model for obesity that describes the interpersonal work needed before and after deliberation about preferences and courses of action.

PRACTICE IMPLICATIONS

The enhanced model can support clinicians in achieving meaningful conversations about obesity and complex chronic disease resulting in care plans that are responsive to and achievable in the patient's lifeworld.

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.

The importance of service-users' perspectives: A systematic review of qualitative evidence reveals overlooked critical features of weight management programmes

Background

Extensive research effort shows that weight management programmes (WMPs) targeting both diet and exercise are broadly effective. However, the critical features of WMPs remain unclear.

Objective

To develop a deeper understanding of WMPs critical features, we undertook a systematic review of qualitative evidence. We sought to understand from a service‐user perspective how programmes are experienced, and may be effective, on the ground.

Search strategy

We identified qualitative studies from existing reviews and updated the searches of one review.

Inclusion criteria

We included UK studies capturing the views of adult WMP users.

Data extraction and synthesis

Thematic analysis was used inductively to code and synthesize the evidence.

Main results

Service users were emphatic that supportive relationships, with service providers or WMP peers, are the most critical aspect of WMPs. Supportive relationships were described as providing an extrinsic motivator or “hook” which helped to overcome barriers such as scepticism about dietary advice or a lack confidence to engage in physical activity.

Discussion and conclusions

The evidence revealed that service‐users’ understandings of the critical features of WMPs differ from the focus of health promotion guidance or descriptions of evaluated programmes which largely emphasize educational or goal setting aspects of WMPs. Existing programme guidance may not therefore fully address the needs of service users. The study illustrates that the perspectives of service users can reveal unanticipated intervention mechanisms or underemphasized critical features and underscores the value of a holistic understanding about “what happens” in complex psychosocial interventions such as WMPs.

Obesity prevention advocacy in Australia: an analysis of policy impact on autonomy

OBJECTIVE

To explore obesity policy options recommended by stakeholders and identify their impact on individual autotomy.

METHODS

Qualitative and quantitative methods were used. A content analysis of submissions to the Australian Government's Inquiry into Obesity was conducted. Each recommendation was categorised by its impact on autonomy, according to existing frameworks. Chi-square test for independence was used to explore the association between autonomy and stakeholder support defined as frequency of recommendation.

RESULTS

The extent of support for a policy option was significantly associated with impact on autonomy (p<0.001). Options that reduce autonomy were least frequently recommended in every setting; but more likely in schools (27%) than other settings (<1%). Recommendations to provide incentives (9%) were more common than disincentives (2%) or restrictions (3%), and those that enhance autonomy were most widely recommended (46%).

CONCLUSIONS

Stakeholders advocated policy options that enhance individual autonomy to a greater extent than those that diminish autonomy. Implications for public health: Targeting obesity policy options that enhance rather than diminish autonomy may be more politically acceptable across most settings, with the exception of schools where more restrictive policy options are appropriate. Re-framing options accordingly may improve leadership by government in obesity policy.

Cognitive and behavioural strategies for self-directed weight loss: systematic review of qualitative studies

AIM

We conducted a systematic review of qualitative studies to examine the strategies people employ as part of self-directed weight loss attempts, map these to an existing behaviour change taxonomy and explore attitudes and beliefs surrounding these strategies.

METHODS

Seven electronic databases were searched in December 2015 for qualitative studies in overweight and obese adults attempting to lose weight through behaviour change. We were interested in strategies used by participants in self-directed efforts to lose weight. Two reviewers extracted data from included studies. Thematic and narrative synthesis techniques were used.

RESULTS

Thirty one studies, representing over 1,000 participants, were included. Quality of the included studies was mixed. The most commonly covered types of strategies were restrictions, self-monitoring, scheduling, professional support and weight management aids. With the exception of scheduling, for which participant experiences were predominantly positive, participants' attitudes and beliefs surrounding implementation of these groups of strategies were mixed. Two new groups of strategies were added to the existing taxonomy: reframing and self-experimentation.

CONCLUSIONS

This review demonstrates that at present, interventions targeting individuals engaged in self-management of weight do not necessarily reflect lived experiences of self-directed weight loss.

Weight loss drugs and lifestyle modification: Perceptions among a diverse adult sample

OBJECTIVES

Explore how adults from diverse racial and socioeconomic backgrounds perceive the use of weight loss drugs (prescription, over-the counter, herbals and supplements) and lifestyle modification.

METHODS

Individual, face-to-face, semi-structured interviews were conducted with persons presenting to an academic hospital-affiliated outpatient pharmacy serving ethnic minorities and low income individuals.

RESULTS

Fifty persons were interviewed, including 21 African Americans, 11 Hispanics and 17 low-income individuals (annual income <$20,000), of whom 33 self-reported as overweight or obese. Ever-users (14/50) and nonusers (36/50) of weight loss drugs expressed a belief in the importance of diet and exercise, but were not necessarily doing so themselves. Fear of side effects and skepticism towards efficacy of drugs deterred use. Some expressed concern over herbal product safety; others perceived herbals as natural and safe. Drugs were often viewed as a short-cut and not a long-term weight management solution.

CONCLUSION

A range of concerns related to the safety and efficacy of weight loss drugs were expressed by this lower income, ethnically diverse population of underweight to obese adults.

PRACTICE IMPLICATIONS

There is need and opportunity for healthcare providers to provide weight loss advice and accurate information regarding the safety and efficacy of various types of weight loss approaches.

Weight loss experiences and willingness to intervention with pharmacotherapy among obese and very obese Danish people

OBJECTIVES

Obesity is a growing issue with increasing impact on healthcare budgets, yet very little is known about weight loss experiences of people with body mass index (BMI)≥30kg/m(2) and their willingness to try and pay for weight loss interventions (WLI). The objective of this survey was to gather knowledge about weight loss experiences among obese and severely obese people.

METHODS

1,003 Danish people >18 years of age with BMI≥30 who wanted to lose weight completed an online survey. Data included demographics, experience with WLI, awareness of anti-obesity medication (AOM), and willingness to try and pay for WLI including AOM.

RESULTS

Respondents had been trying to lose weight for several years (medium [25% percentile;75% percentile]);5.1[2.0;10.3] years (BMI 30-35) and 10.0 [5.0;20.0] (very obese (BMI>35) with co-morbidities (OWC). The desired weight loss was 20.0 [15.0;25.0] kg (BMI 30-35) and 35.0 [28.0;47.5] kg (OWC). Independent of educational level and gender, health concern was the main incentive for weight loss. Several WLI had been tried repeatedly, yet 60% of respondents with BMI 30-35 and 50% of the OWC were unaware of AOM. Among those who had tried AOM, side effects and lack of effectiveness were the main reasons to stop. 50-73% were willing to try AOM dependent on expected weight loss. Willingness to try and pay for new AOM was strongest for the OWC.

CONCLUSION

Respondents had made repeated attempts for up to a decade to lose weight, yet remained far from their ideal weight. They had spent a substantial amount of money on WLI, had limited information of AOM, and indicated a desire for increased professional support.

Non-communicable disease risk factors and treatment preference of obese patients in Cape Town

BACKGROUND

Insights into the characteristics of treatment seekers for lifestyle changes and treatment preferences are necessary for intervention planning.

AIM

To compile a profile of treatment-seeking obese patients with non-communicable diseases (NCDs) or NCD risk factors and to compare patients who choose group-based (facility-based therapeutic group [FBTG]) versus usual care (individual consultations) treatment.

SETTING

A primary healthcare facility in Cape Town, South Africa.

METHODS

One hundred and ninety-three patients were recruited in this cross-sectional study. Ninety six chose FBTG while 97 chose usual care. A questionnaire, the hospital database and patients' folders were used to collect data. Weight, height and waist circumference were measured. STATA 11.0 was used for descriptive statistics and to compare the two groups.

RESULTS

The subjects' mean age was 50.4 years, 78% were women and of low education levels and income, and 41.5% had type 2 diabetes, 83.4% hypertension and 69.5% high cholesterol. Mean (s.d.) HbA1c was 9.1 (2.0)%, systolic BP 145.6 (21.0) mmHg, diastolic BP 84.5 (12.0) mmHg, cholesterol 5.4 (1.2) mmol/L), body mass indicator (BMI) 39.3 (7.3) kg/m2 and waist circumference 117 (12.6) cm). These figures were undesirable although pharmacological treatment for diabetes and hypertension was in place. Only 14% were physically active, while TV viewing was > 2h/day. Mean daily intake of fruit and vegetables (2.2 portions/day) was low while added sugar (5 teaspoons) and sugar-sweetened beverages (1.3 glasses) were high. Usual care patients had a higher smoking prevalence, HbA1c, number of NCD risk factors and refined carbohydrate intake, and a lower fruit and vegetable intake.

CONCLUSION

Treatment seekers were typically middle-aged, low income women with various modifiable and intermediate risk factors for NCDs. Patients choosing usual care could have more NCD risks.

Direct observation of weight counselling in primary care: alignment with clinical guidelines

Primary care physicians provide care to a disproportionate number of overweight and obese patients and are uniquely positioned to help patients manage their weight in the context of a continuity relationship. The US National Heart, Lung and Blood Institute (NHLBI) developed evidence-based guidelines for the effective and efficient care of overweight/obese patients, but little is known about the use of these guidelines in practice. To determine the content of weight discussions and assess the elements of the NHLBI guidelines that were accomplished, office visits of 544 adult, overweight/obese patients to 28 primary care physicians were observed and audio recorded. Associations between type of weight management discussion and patient, physician and visit characteristics were examined. Fifty per cent (n = 270) of visits included weight discussions; 47% and 38% included use of at least one NHLBI assessment or treatment element during discussions about weight, respectively. Only 35% (n = 193) of discussions included an assessment and treatment strategy; none included all NHLBI-recommended elements. Overall, adherence to guidelines was poor, particularly with regard to reporting body mass index to the patient, measuring waist circumference and setting realistic weight loss goals. Weight discussions did not clearly vary by the patient, physician or visit characteristics examined. These findings suggest opportunities to develop and further tailor resources for improved physician training in patient weight management communication and treatment techniques that are both consistent with current standards for effective, evidence-based care and efficient enough for routine use during busy primary care visits.

A qualitative study of the determinants of dieting and non-dieting approaches in overweight/obese Australian adults

Background

Dieting has historically been the main behavioural treatment paradigm for overweight/obesity, although a non-dieting paradigm has more recently emerged based on the criticisms of the original dieting approach. There is a dearth of research contrasting why these approaches are adopted. To address this, we conducted a qualitative investigation into the determinants of dieting and non-dieting approaches based on the perspectives and experiences of overweight/obese Australian adults.

Methods

Grounded theory was used inductively to generate a model of themes contrasting the determinants of dieting and non-dieting approaches based on the perspectives of 21 overweight/obese adults. Data was collected using semi-structured interviews to elicit in-depth individual experiences and perspectives.

Results

Several categories emerged which distinguished between the adoption of a dieting or non-dieting approach. These categories included the focus of each approach (weight/image or lifestyle/health behaviours); internal or external attributions about dieting failure; attitudes towards established diets, and personal autonomy. Personal autonomy was also influenced by another category; the perceived knowledge and self-efficacy about each approach, with adults more likely to choose an approach they knew more about and were confident in implementing. The time perspective of change (short or long-term) and the perceived identity of the person (fat/dieter or healthy person) also emerged as determinants of dieting or non-dieting approaches respectively.

Conclusions

The model of determinants elicited from this study assists in understanding why dieting and non-dieting approaches are adopted, from the perspectives and experiences of overweight/obese adults. Understanding this decision-making process can assist clinicians and public health researchers to design and tailor dieting and non-dieting interventions to population subgroups that have preferences and characteristics suitable for each approach.