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

Missed diagnosis-a major barrier to patient access to obesity healthcare in the primary care setting

OBJECTIVE

To investigate whether individuals with an elevated BMI measurement, for whom a diagnosis of overweight or obesity (OW/OB) is not recorded, are less likely to be offered clinical care for obesity compared to those with a recorded diagnosis.

SUBJECTS

A retrospective cohort study using the electronic medical record database of Maccabi Healthcare Services (MHS) in Israel. Included were 200,000 adults with BMI ≥ 25 kg/m2 measurement recorded during a primary care visit between 2014 and 2020, and no prior diagnosis of OW/OB or related co-morbidities.

METHODS

The relationships between a recorded diagnosis of OW/OB and two composite outcomes: 1. A composite of referrals to screening tests for metabolic complications; 2. A composite of weight loss intervention and follow up, were analyzed using multivariate logistic regression models.

RESULTS

In only 18% of individuals, a diagnosis of OW/OB was recorded. After adjusting for multiple potential confounding factors, individuals who received a recorded diagnosis were 18% more likely to be offered an evaluation for obesity-related metabolic complication, (OR 1.18, 95% CI 1.15-1.21, p < 0.001), and almost twice as likely to be offered intervention and follow up for their excess body weight (OR 1.84, 95% CI 1.76-1.94, p < 0.001) compared to individuals with missed diagnosis. These results persisted after adjusting for inter-physician variability. In addition, male sex, older age, and Arab sector were all associated with lower rates of weight loss intervention and follow up, while young individuals were less likely to be screened for metabolic complications.

CONCLUSION

Beyond BMI measurement, a recorded diagnosis of OW/OB is associated with statistically and clinically significant higher rates of performance of obesity care and intervention. Undiagnosed OW/OB presents a significant clinical opportunity, as recording a diagnosis of OW/OB would predict improved patient access to obesity healthcare and improved clinical outcomes.

Toward evidence-based communication on overweight body mass index and mortality

BACKGROUND

Reducing overweight and obesity has been a longstanding focus of public health messaging and physician-patient interactions. Clinical guidelines by major public health organizations describe both overweight and obesity as risk factors for mortality and other health conditions. Accordingly, a majority of primary care physicians believe that overweight BMI (even without obesity) strongly increases mortality risk.

MAIN POINTS

The current evidence base suggests that although both obese BMI and underweight BMI are consistently associated with increased all-cause mortality, overweight BMI (without obesity) is not meaningfully associated with increased mortality. In fact, a number of studies suggest modest protective, rather than detrimental, associations of overweight BMI with all-cause mortality. Given this current evidence base, clinical guidelines and physician perceptions substantially overstate all-cause mortality risks associated with the range of BMIs classified as "overweight" but not "obese." Discrepancies between evidence and communication regarding mortality raise the question of whether similar discrepancies exist for other health outcomes.

CONCLUSIONS

Health communication that inaccurately conveys current evidence may do more harm than good; this applies to communication from health authorities to health practitioners as well as to communication from health practitioners to individual patients. We give three recommendations to better align health communication with the current evidence. First, recommendations to the public and health practitioners should distinguish overweight from obese BMI and at this time should not describe overweight BMI as a risk factor for all-cause mortality. Second, primary care physicians' widespread misconceptions about overweight BMI should be rectified. Third, the evidence basis for other potential risks or benefits of overweight BMI should be rigorously examined and incorporated appropriately into health communication.

Dutch GPs' perspectives on addressing obesity: a qualitative study

BACKGROUND

Early diagnosis and treatment of obesity in primary care may help to tackle the obesity pandemic. Nonetheless, GPs frequently fail to address obesity and demonstrate limited adherence to guidelines.

AIM

To explore Dutch GPs' perspectives on addressing obesity regarding the following three target behaviours: discussing weight; diagnosing; and referring patients with obesity.

DESIGN & SETTING

A qualitative focus group study with Dutch GPs.

METHOD

Six focus groups were conducted with a purposive sample of 21 GPs. Thematic analysis was performed using deductive coding, according to the Theoretical Domains Framework (TDF).

RESULTS

For discussing weight, the main barriers identified were a presented complaint unrelated to obesity (environmental context and resources), concerns about a negative response from the patient (beliefs about consequences), and worries about obesity being a sensitive subject to discuss (emotions). A long-term trustworthy relationship (social influences) facilitated discussing weight. For diagnosing patients with obesity, the main barriers were related to resources; for example, lack of (appropriate) measuring equipment and time (environmental context and resources). For referring patients with obesity, the main barriers were no referral options nearby (environmental context and resources), and doubts about the positive effects of the referral on weight change (beliefs about consequences).

CONCLUSION

Different barriers for discussing weight, diagnosing, and referring patients with obesity were identified, underscoring the importance for tailored interventions to these specific behaviours. Improving knowledge and skills of GPs seems insufficient as this study showed that particular attention should be paid to establishing long-term relationships, addressing GPs' beliefs about consequences, and creating a supportive environment with sufficient time and resources.

Patients' experience of accessing healthcare for obesity in Peninsular Malaysia: a qualitative descriptive study

OBJECTIVE

To explore patients' experiences accessing healthcare for obesity and their perceived behaviour changes following the care.

DESIGN

Using a descriptive qualitative research approach informed by Levesque's framework of access to healthcare, we conducted phone interviews in the Malaysian language, which were audio-recorded and transcribed verbatim. Data were analysed inductively using a reflexive thematic analysis approach.

SETTING

Primary care clinics in five states in Peninsular Malaysia.

PARTICIPANTS

Adult patients with obesity receiving face-to-face care for obesity from healthcare providers in Peninsular Malaysia.

RESULTS

We interviewed 22 participants aged 24-62, with the majority being female (77%), Malay (95%), married (73%) and with tertiary education (82%). Most participants attended obesity management services at public primary care clinics. We identified five themes: (1) moving from perceiving the need to seeking obesity care is a non-linear process for patients, (2) providers' words can inspire patients to change, (3) patients' needs and preferences are not adequately addressed in current obesity care, (4) over-focusing on weight by patients and healthcare providers can lead to self-blame and loss of hope for patients and (5) obesity healthcare can have consequences beyond weight loss.

CONCLUSION

Patients lack the self-regulatory skills to continue their lifestyle changes and struggle with self-blame and hopelessness. Over-focusing on weight by patients and obesity healthcare increase patients' self-stigmatisation. While provider-initiated weight discussions and engaging and personalised consultation provide the initial step towards weight management, obesity healthcare could be enhanced by behavioural support and patient education on the complexity of obesity. Further considerations could be given to shifting from a weight-centric to a more holistic health-centred approach in obesity healthcare.

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.

Attitude and Belief of Healthcare Professionals Towards Effective Obesity Care and Perception of Barriers; An Updated Systematic Review and Meta-analysis

BACKGROUND

Obesity is a serious chronic disease that adversely affects health and quality of life. However, a significant percentage of people do not participate in or adhere to weight loss programs. Therefore, a multidisciplinary approach is needed to identify critical barriers to effective obesity management and to examine health practitioners' attitudes and behaviors towards effective obesity treatment.

METHODS

This systematic review was conducted in accordance with PRISMA 2020. Eligible studies were identified through a systematic review of the literature using Medline, Scopus, Cochrane, Google Scholar, Web of Science, and Embase databases from January 1, 2011 to March 2, 2021.

RESULTS

A total of 57 articles were included. Data on 12663 physicians were extracted from a total of 35 quantitative articles. Some of the most commonly perceived attitude issues included "obesity has a huge impact on overall health", "obesity is a disease" and "HCPs are to blame". Health professionals were more inclined to believe in "using BMI to assess obesity," "advice to increase physical activity," and "diet/calorie reduction advice." The major obstacles to optimal treatment of obesity were "lack of motivation", "lack of time" and "lack of success".

CONCLUSION

Although the majority of health care professionals consider obesity as a serious disease which has a large impact on overall health, counseling for lifestyle modification, pharmacologic or surgical intervention occur in almost half of the visits. Increasing the length of physician visits as well as tailoring appropriate training programs could improve health care for obesity.

The perceptions of healthcare practitioners on obesity management in Peninsular Malaysia: a cross-sectional survey

BACKGROUND

Practitioners' perceptions of patients with obesity and obesity management shape their engagement in obesity care delivery. This study aims to describe practitioners' perceptions, experiences and needs in managing patients with obesity, determine the extent of weight stigma among health practitioners, and identify the factors associated with negative judgment towards patients with obesity.

METHODS

A cross-sectional online survey was conducted from May to August 2022 with health practitioners commonly involved in obesity management in Peninsular Malaysia, including doctors in primary care, internal medicine and bariatric surgery, and allied health practitioners. The survey explored practitioners' perceptions, barriers and needs in managing obesity, and evaluated weight stigma using the Universal Measures of Bias - Fat (UMB Fat) questionnaire. Multiple linear regression analysis was used to identify demographic and clinical-related factors associated with higher negative judgment towards patients with obesity.

RESULTS

A total of 209 participants completed the survey (completion rate of 55.4%). The majority (n = 196, 94.3%) agreed that obesity is a chronic disease, perceived a responsibility to provide care (n = 176, 84.2%) and were motivated to help patients to lose weight (n = 160, 76.6%). However, only 22% (n = 46) thought their patients were motivated to lose weight. The most frequently reported barriers to obesity discussions were short consultation time, patients' lack of motivation, and having other, more important, concerns to discuss. Practitioners needed support with access to multi-disciplinary care, advanced obesity training, financing, comprehensive obesity management guidelines and access to obesity medications. The mean (SD) of the UMB Fat summary score was 2.99 (0.87), with the mean (SD) domain scores ranging between 2.21 and 4.36 (1.06 to 1.45). No demographic and clinical-related factors were significantly associated with negative judgment from the multiple linear regression analyses.

CONCLUSION

Practitioners in this study considered obesity a chronic disease. While they had the motivation and capacity to engage in obesity management, physical and social opportunities were the reasons for not discussing obesity with their patients. Practitioners needed more support to enhance their capability and opportunity to engage with obesity management. Weight stigma in healthcare settings in Malaysia should be addressed, given the possibility of hindering weight discussions with patients.

The impact of obesity: a narrative review

Obesity is a disease with a major negative impact on human health. However, people with obesity may not perceive their weight to be a significant problem and less than half of patients with obesity are advised by their physicians to lose weight. The purpose of this review is to highlight the importance of managing overweight and obesity by discussing the adverse consequences and impact of obesity. In summary, obesity is strongly related to >50 medical conditions, with many of them having evidence from Mendelian randomisation studies to support causality. The clinical, social and economic burdens of obesity are considerable, with these burdens potentially impacting future generations as well. This review highlights the adverse health and economic consequences of obesity and the importance of an urgent and concerted effort towards the prevention and management of obesity to reduce the burden of obesity.

Perspectives of healthcare professionals on facilitators, barriers and needs in children with obesity and their parents in achieving a healthier lifestyle

Objective

To explore the perspectives of healthcare professionals (HCPs) within an integrated care approach on the facilitators, barriers and needs in children with obesity and their parents in achieving a healthier lifestyle.

Methods

Semi-structured interviews were conducted with eighteen HCPs working within a Dutch integrated care approach. The interviews were analyzed by performing a thematic content analysis.

Results

Main facilitators identified by HCPs were support from parents and the social network. Main barriers were first and foremost family's lack of motivation, which was singled out as a precondition for starting the behavior change process. Other barriers were child's socio-emotional problems, parental personal problems, lack of parenting skills, parental lack of knowledge and skills regarding a healthier lifestyle, parental lack of problem awareness and HCP's negative attitude. To overcome these barriers, main needs that HCPs suggested were a tailored approach in healthcare and a supportive HCP.

Conclusion

The HCPs identified the breadth and complexity of underlying factors of childhood obesity, of which the family's motivation was pointed out as a critical factor to address.

Innovation

Understanding the patient's perspective is important for HCPs to provide the tailored care needed to address the complexity of childhood obesity.

Enablers and barriers to implementing obesity assessments in clinical practice: a rapid mixed-methods systematic review

OBJECTIVES

This systematic review aims to improve our knowledge of enablers and barriers to implementing obesity-related anthropometric assessments in clinical practice.

DESIGN

A mixed-methods systematic review.

DATA SOURCES

Medline, Embase and CINAHL to November 2021.

ELIGIBILITY CRITERIA

Quantitative studies that reported patient factors associated with obesity assessments in clinical practice (general practice or primary care); and qualitative studies that reported views of healthcare professionals about enablers and barriers to their implementation.

DATA EXTRACTION AND SYNTHESIS

We used random-effects meta-analysis to pool ratios for categorical predictors reported in ≥3 studies expressed as pooled risk ratio (RR) with 95% CI, applied inverse variance weights, and investigated statistical heterogeneity (I²), publication bias (Egger's test), and sensitivity analyses. We used reflexive thematic analysis for qualitative data and applied a convergent integrated approach to synthesis.

RESULTS

We reviewed 22 quantitative (observational) and 3 qualitative studies published between 2004 and 2020. All had ≥50% of the quality items for risk of bias assessments. Obesity assessment in clinical practice was positively associated with patient factors: female sex (RR 1.28, 95% CI 1.10 to 1.50, I² 99.8%, mostly UK/USA), socioeconomic deprivation (RR 1.21, 95% CI 1.18 to 1.24, I² 73.9%, UK studies), non-white race/ethnicity (RR 1.27, 95% CI 1.03 to 1.57, I² 99.6%) and comorbidities (RR 2.11, 95% CI 1.60 to 2.79, I² 99.6%, consistent across most countries). Obesity assessment was also most common in the heaviest body mass index group (RR 1.55, 95% CI 0.99 to 2.45, I² 99.6%). Views of healthcare professionals were positive about obesity assessments when linked to patient health (convergent with meta-analysis for comorbidities) and if part of routine practice, but negative about their role, training, time, resources and incentives in the healthcare system.

CONCLUSIONS

Our evidence synthesis revealed several important enablers and barriers to obesity assessments that should inform healthcare professionals and relevant stakeholders to encourage adherence to clinical practice guideline recommendations.

Predictors of weight discussion in primary care consultations: A multilevel modeling approach

OBJECTIVE

To understand how primary care weight-related communication processes are influenced by individual differences in primary care practitioner (PCP) and patient characteristics and communication use.

METHODS

Two multilevel logistic regression models were calculated to predict the occurrence of 1) weight-related discussion and 2) weight-related consultation outcomes. Coded communication data (Roter Interaction Analysis System) from 218 video-recorded consultations between PCPs and patients with overweight and obesity in Scottish primary care practices were combined with their demographic data to develop the multilevel models.

RESULTS

Weight-related discussions were more likely to occur when a greater proportion of PCP's total communication was partnership building and activating communication. More discrete weight discussions during a consultation predicted weight-related consultation outcomes. Patient BMI positively predicted both weight-related discussion and consultation outcomes.

CONCLUSION

This work demonstrates that multilevel modeling is a viable approach to investigating coded primary care weight-related communication data and that it can provide insight into the impact that various patient and PCP factors have on these communication processes.

PRACTICE IMPLICATIONS

Through the increased use of partnership building and activating communications, and by engaging in shorter, but more frequent, discussions about patient weight, PCPs may better facilitate weight-related discussion and weight-related consultation outcomes for their patients.

Qualitative study on the key elements of obesity counseling in Korean Medicine

INTRODUCTION

The increasing prevalence of obesity worldwide necessitates the provision of support for many patients. Patients with obesity appreciate receiving advice from doctors. Previous studies have qualitatively explored clinicians' counseling for weight loss; however, this is limited to primary physicians or general practitioners working in community health centers. In contrast, Korean Medicine Doctors (KMDs) have treated patients with obesity using a holistic approach with a multicomponent approach on counseling. However, there is currently no data regarding KMDs' consulting practices for weight loss. Therefore, the present study will explore KMDs' experience in counseling for weight loss and describe the constituents of counseling for weight loss in Korean medicine practice.

METHODS

This qualitative study utilizes a phenomenological framework. The KMDs who have worked >1 year as practitioners in treating patients with obesity will be invited to describe their lived experiences of counseling patients for weight loss. Purposive and snowball sampling will be undertaken to ensure that the sample provides information-rich cases that are representative of KMDs' experiences of counseling for weight loss. Face-to-face, individual, and semi-structured interviews will be conducted with the participants, which will be analyzed using a phenomenological method.

ETHICS AND DISSEMINATION

Ethical approval was granted by the Human Research Ethics Committee of the Korea Institute of Oriental Medicine (I-1908/006-001). The results will be disseminated via journal articles and conference presentations.

TRIAL REGISTRATION NUMBER

Korean Clinical Trial Registry, KCT0004985.

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

Background

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

Methods

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

Results

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

Conclusions

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