The role of primary care in adult weight management: qualitative interviews with key stakeholders in weight management services

Barriers and enablers to effective weight management for people living with overweight and obesity: A rapid scoping review

A scoping review was conducted to identify barriers and enablers to effective weight management in healthcare settings for people living with overweight and obesity in English-speaking high-income countries. Peer-reviewed and gray literature were systematically searched in June 2024. Data were analyzed using inductive thematic analysis. Of the 15,684 unique articles identified and screened for relevance, 216 studies were included. Healthcare-related barriers and enablers to weight management were organized under three themes: a) healthcare provider-related factors, b) provision of care, and c) policy/funding. Prominent barriers included healthcare provider knowledge deficits and low prioritization of obesity management, mainly in the primary care setting. Weight management beyond the primary care setting was found to be especially challenging, with poor referral pathways, service fragmentation, lack of multidisciplinary practice, and restricted eligibility criteria, hindering the accessibility of services. Developing consistent policies and guidelines, improving the education of healthcare providers, and increasing funding to provide low-cost comprehensive care, were identified as enablers to access and uptake of weight management services. Considerable overlap in the identified barriers existed across healthcare providers and settings. A whole health system approach to minimize barriers and strengthen enablers to weight management services is needed, to address rising obesity rates.

Interprofessional follow-up for people at risk of type 2 diabetes in primary healthcare - a randomized controlled trial with embedded qualitative interviews

OBJECTIVE

To examine the effects of an empowerment-based interprofessional lifestyle intervention program among people at risk of type 2 diabetes on knowledge, skills, and confidence in self-management, health, psychological well-being, and lifestyle characteristics, and to explore the participants' perceptions of participating in the intervention.

DESIGN AND METHODS

In line with the Medical Research Council complex interventions research methods framework, we conducted a randomized controlled trial with embedded qualitative interviews in primary healthcare clinics in Norway between 2019-2021. Of the patients at risk (The Finnish Diabetes Risk Score Calculator (FINDRISC) ≥15 or Body Mass Index (BMI) ≥30) 142 accepted the invitation, and 14 participants from the intervention group participated in individual interviews after the 12-month follow-up. Our primary outcome was the Patient Activation Measure (PAM-13). Secondary outcomes were EQ-5D-5L, EQ-VAS, WHO-Overall health, WHO-Overall QOL, weight, height, waist circumference, and regularity of physical activity. We used thematic analysis to analyse the qualitative data.

RESULTS

There was no clinically relevant differences of neither the primary nor the secondary endpoints between intervention and control group. As to the qualitative data, we identified two distinct features: 'Meaningful perspectives on lifestyle changes' and 'Lifestyle change is not a linear process due to challenges faced along the way' putting ownership of their choices in life into picture.

CONCLUSION

The negative results of the RCT stand in contrast to the findings given by the participants voices, perceiving the intervention as a key eye opener placing their health challenges in perspective. How to interpret these seemingly conflicting findings of participants being seen, heard, and understood, helping them to take more conscious ownership of their choices in life, and at the same time demonstrating no improvements in symptoms or measures, is a dilemma that needs further exploration. We should be careful to implement interventions that do not demonstrate any effects on the quantitative outcomes.

Supporting healthcare professionals to address child weight with parents: a qualitative study

BACKGROUND

Primary care and community healthcare professionals (HCPs) are well placed to discuss child excess weight with parents and support them to make changes. However, HCPs have concerns about addressing this issue. There is a need to understand the factors that influence HCPs in initiating these conversations to inform strategies to support them.

AIM

To explore with HCPs, working in primary care and community settings, their experiences of having conversations about child weight with parents, and the factors that create barriers or facilitate them to have these conversations.

DESIGN AND SETTING

A qualitative study with GPs, primary care nurses (PNs), and school nurses (SNs) in England.

METHOD

GPs and PNs were recruited to participate in semi-structured interviews. SNs from a community healthcare NHS trust were recruited to participate in focus groups. Vignettes were used to stimulate discussion. Data were analysed guided by the Framework approach.

RESULTS

Thirteen GPs, seven PNs, and 20 SNs participated. The following three themes were identified regarding barriers to HCPs having conversations about child excess weight: structural and organisational; HCP related; and parent or family related. The themes identified for the factors that facilitate these conversations were: structural changes (for example, dedicated appointments, access to weight assessment data, joined-up working across agencies); HCP approaches (for example, providing appropriate dietary and physical activity advice); and HCP knowledge and skills (for example, enhancing HCPs' general and weight management-related skills and knowledge of child weight management services).

CONCLUSION

A range of barriers exist to HCPs addressing child excess weight with parents in primary care and community settings. Actions to effect structural changes and support HCPs in developing relevant knowledge and skills are required to overcome these barriers.

Evaluation of an interprofessional follow-up intervention among people with type 2 diabetes in primary care-A randomized controlled trial with embedded qualitative interviews

With an ageing population and improved treatments people live longer with their chronic diseases, and primary care clinics face more costly and difficult-to-treat multimorbid patients. To meet these challenges, current guidelines for the management of type 2 diabetes suggest that an interprofessional team should collaborate to enhance the delivery of worthwhile self-management support interventions. In this study, we aimed to evaluate the effects of an empowerment-based interprofessional follow-up intervention in people with type 2 diabetes in primary care on patient-reported outcomes, biomarkers and weight, and to explore the experiences of patients attending the intervention. We invited patients during regular visits to their general practitioners. The 12-month intervention included 1) empowerment-based counselling; 2) a standardized medical report. The control group received consultations with physicians only. The primary outcome was the Patient Activation Measure, a patient-reported measure assessing individual knowledge, skills, and confidence integral to managing one's health and healthcare. After the trial we conducted qualitative interviews. We observed no difference in the primary outcome scores. On secondary outcomes we found a significant between-group intervention effect in favor of the intervention group, with mean differences in glycemic control after 12 months (B [95% CI] = -8.6 [-17.1, -0.1] mmol/l; p = 0.045), and significant within-group changes of weight (B [95% CI] = -1.8 kg [-3.3, -0.3]; p = 0.02) and waist circumference (B [95% CI] = -3.9 cm [-7.3, -0.6]; p = 0.02). The qualitative data showed that the intervention opened patients' eyes for reflections and greater awareness, but they needed time to take on actions. The patients emphasized that the intervention gave rise to other insights and a greater understanding of their health challenges. We suggest testing the intervention among patients with larger disease burden and a more expressed motivation for change.

A Qualitative Exploration of Patient and Staff Experiences of the Receipt and Delivery of Specialist Weight Management Services in the UK

BACKGROUND

Addressing the increasing prevalence of obesity is a global public health priority. Severe obesity (body mass index > 40) reduces life expectancy, due to its association with people developing complications (e.g. diabetes, cancer, cardiovascular disease), and greatly impairs quality of life. The National Health Service (NHS) in the UK provides specialist weight management services (SWMS) for people with severe obesity, but key uncertainties remain around patient access to and engagement with weight management services, as well as pathways beyond the service.

METHODS

In this multiple methods study, using online forum data and semi-structured interviews, stakeholders' experiences of delivering and receiving SWMS were explored. Using the web search engine Google with keywords and web address (URL) identifiers, relevant public online platforms were sourced with snowball sampling and search strings used to identify threads related to people's experiences of accessing SWMS (n = 57). Interviews were conducted with 24 participants (nine patients, 15 staff), and data from all sources were analysed thematically using the framework approach.

RESULTS

Six themes related to access to and engagement with SWMS emerged during data analysis: (1) making the first move, (2) uncertainty and confusion, (3) resource issues, (4) respect and understanding, (5) mode of delivery, and (6) desire for ongoing support.

CONCLUSION

There is a mixed and varied picture of SWMS provision across the UK. The service offered is based on local clinical decision making and available resources, resulting in a range of patient experiences and perspectives. Whilst service capacity issues and patient anxiety were seen as barriers to accessing care, peer support and positive clinical and group interactions (connectedness between individuals) were considered to increase engagement.

Animal obesity: What insights can a one health approach offer when it comes to veterinarians 'making every contact count'?

There is an overweight/obesity crisis in both human and companion animal populations globally. Veterinarians have an ethical obligation to protect animal welfare and, therefore, have a duty to intervene by supporting their clients in changing care plans to mitigate and prevent pet overweight/obesity. Currently, there is limited evidence in veterinary contexts for when and how this can be done effectively. In contrast, a more comprehensive body of literature has been developed on how human healthcare practitioners 'make every contact count' (MECC). This review begins by briefly exploring the cross-species multifactorial causes of overweight/obesity, before considering the literature regarding whether veterinarians reliably address overweight/obesity and the obstacles they encounter. The review then explores the evidence from human healthcare contexts in terms of how person-centred and health 'coaching-style' MECC interventions have supported weight management in adult and child populations and the barriers practitioners face when implementing these interventions. The final section interprets this literature to provide a fresh 'lens' through which veterinarians' concerns can be understood. Recommendations are made for enhancing veterinarians' capacity to develop the knowledge and skills needed for successful outcomes when MECC. Opportunities for developing local multi-stakeholder/agency teams taking a 'one health' approach are considered.

Changing the narrative around obesity in the UK: a survey of people with obesity and healthcare professionals from the ACTION-IO study

OBJECTIVES

To investigate the perceptions, attitudes, behaviours and potential barriers to effective obesity care in the UK using data collected from people with obesity (PwO) and healthcare professionals (HCPs) in the Awareness, Care, and Treatment In Obesity maNagement-International Observation (ACTION-IO) study.

DESIGN

UK's PwO (body mass index of ≥30 kg/m² based on self-reported height and weight) and HCPs who manage patients with obesity completed an online survey.

RESULTS

In the UK, 1500 PwO and 306 HCPs completed the survey. Among the 47% of PwO who discussed weight with an HCP in the past 5 years, it took a mean of 9 years from the start of their struggles with weight until a discussion occurred. HCPs reported that PwO initiated 35% of weight-related discussions; PwO reported that they initiated 47% of discussions. Most PwO (85%) assumed full responsibility for their own weight loss. The presence of obesity-related comorbidities was cited by 76% of HCPs as a top criterion for initiating weight management conversations. The perception of lack of interest (72%) and motivation (61%) in losing weight was reported as top reasons by HCPs for not discussing weight with a patient. Sixty-five per cent of PwO liked their HCP bringing up weight during appointments. PwO reported complex and varied emotions following a weight loss conversation with an HCP, including supported (36%), hopeful (31%), motivated (23%) and embarrassed (17%). Follow-up appointments were scheduled for 19% of PwO after a weight discussion despite 62% wanting follow-up.

CONCLUSIONS

The current narrative around obesity requires a paradigm shift in the UK to address the delay between PwO struggling with their weight and discussing weight with their HCP. Perceptions of lack of patient interest and motivation in weight management must be challenged along with the blame culture of individual responsibility that is prevalent throughout society. While PwO may welcome weight-related conversations with an HCP, they evoke complex feelings, demonstrating the need for sensitivity and respect in these conversations.

TRIAL REGISTRATION NUMBER

NCT03584191.

'Water dripping on a stone': a feasibility study of a healthy weight management conversation approach in routine general practice consultations

BACKGROUND

Primary health care has an important role to play in the management of weight and yet discussions of healthy weight management do not occur optimally, indicating a need for simple tools and training in brief weight counselling. The 'FABS' approach (focusing on four topic areas: Food, Activity, Behaviour and Support) was developed to address this.

OBJECTIVES

To explore the feasibility of the 'FABS' approach within routine general practice consultations and its effectiveness in facilitating healthy weight conversations.

METHOD

The FABS approach was run for a trial period in five New Zealand general practices. The approach entailed staff training, the addition to the practice patient management system of a template outlining potential topics for discussion and a patient handout. GPs were asked to use the approach with any adult patient with a body mass index of over 28 kg/m2. A descriptive analysis of anonymized quantitative practice data was conducted, with limited qualitative data from an online clinician questionnaire and interviews with GPs and patients.

RESULTS

Over 4 months, the template was opened 862 times by 27 clinicians in 830 patient consultations. All FABS topics were raised at least once. Physical activity was raised most frequently, followed by two food-related topics. There was variation between practices and between GPs. GPs tended to raise more topics within a single consultation than the training recommended. The limited clinician survey results and patient interviews also indicated positive responses to the approach.

CONCLUSIONS

It is possible to provide an infrastructure for healthy weight conversation approaches within general practice so that patients receive supportive and consistent messages on a regular basis. General practice is an appropriate setting for this due to the ongoing relationships with patients and team-based approach, but there is a need for effective training and education to ensure appropriate and effectively delivery.

Professional stakeholder's views of adolescent weight management programmes: a qualitative study

OBJECTIVE

Family-based multi-component weight management programmes are recommended for adolescents with obesity in England and Wales, however, these programmes suffer from poor uptake and high attrition rates. This study aimed to gather the views of professional stakeholders in a UK weight management programme to identify potential areas to target to improve engagement and success for such programmes.

RESULTS

Semi-structured interviews were conducted with those involved in the commissioning, referral, coordination or delivery of a weight management programme (n = 11). Interviews were analysed using qualitative content analysis. Three main categories developed: professional support, tailoring and intervention content. Participants recognised the importance of support from experienced professionals, as well as family and peers. There was agreement that longer-term support was needed for adolescents with obesity; suggestions included integrating follow-up support with schools and leisure services. Emotional and psychological support must be prioritised. Having a variety of delivery modes, such as group and one to one, particularly in the home environment, were recommended. Stakeholders agreed that weight management programmes for adolescents need to be more proactive at incorporating technology. By acting on the views of those that work closely with adolescents, engagement with weight management programmes may be improved.

A study using semi-structured interview and Delphi survey to explore the barriers and enabling factors that influence access and utilisation of weight management services for people living with morbid obesity: A patient and professional perspective

BACKGROUND

A quarter of the United Kingdom's population are living with obesity, a disease that causes an estimated 30 000 deaths each year. This coincides with an under-utilisation of weight management services across the country with the majority of patients with morbid obesity having no record of any weight loss intervention at all. This study explores the factors that influence patient access to weight management services.

METHODOLOGY

Expert opinion was obtained using semi-structured interviews and the Delphi methodology. Participants were selected from primary and secondary healthcare settings. Healthcare professionals (HCPs) had experience working in weight management services or in services dealing with obesity-related comorbidities. Patients had experience in attending a variety weight management services.

RESULTS

Nineteen participants completed all aspects of the study. The main barriers included negative perceptions, low mood/depression, obesity not being considered as a serious disease, lack of access to services for housebound patients and disproportionate commissioning. Suggested facilitating factors to improve access included the education of all HCPs about obesity, improving HCP communication with patients, and broadening the number of HCP's that are able to refer to weight management services.

CONCLUSIONS

Future services must prioritise the education of all HCPs and the public to combat the stigma of obesity and its impact on health. National commissioning guidelines in partnership with advocates of obesity should seek to streamline referral pathways, broaden referral sources and increase the availability of specialist services. Awareness of these factors when designing future weight management services will help to improve their utilisation.

Assessment of Physician Priorities in Delivery of Preventive Care

IMPORTANCE

Primary care physicians have limited time to discuss preventive care, but it is unknown how they prioritize recommended services.

OBJECTIVE

To understand primary care physicians' prioritization of preventive services.

DESIGN, SETTING, AND PARTICIPANTS

This online survey was administered to primary care physicians in a large health care system from March 17 to May 12, 2017. Physicians were asked whether they prioritize preventive services and which factors contribute to their choice (5-point Likert scale). Results were analyzed from July 8, 2017, to September 19, 2019.

EXPOSURES

A 2 × 2 factorial design of 2 hypothetical patients: (1) a 50-year-old white woman with hypertension, type 2 diabetes, hyperlipidemia, obesity, a 30-pack-year history of smoking, and a family history of breast cancer; and (2) a 45-year-old black man with hypertension, hyperlipidemia, obesity, a 30-pack-year history of smoking, and a family history of colorectal cancer. Two visit lengths (40 minutes vs 20 minutes) were given. Each patient was eligible for at least 11 preventive services.

MAIN OUTCOMES AND MEASURES

Physicians rated their likelihood of discussing each service during the visit and reported their top 3 priorities for patients 1 and 2. Physician choices were compared with the preventive services most likely to improve life expectancy, using a previously published mathematical model.

RESULTS

Of 241 physicians, 137 responded (57%), of whom 74 (54%) were female and 85 (62%) were younger than 50 years. Physicians agreed they prioritized preventive services (mean score, 4.27 [95% CI, 4.12-4.42] of 5.00), mostly by ability to improve quality (4.56 [95% CI, 4.44-4.68] of 5.00) or length (4.53 [95% CI, 4.40-4.66] of 5.00) of life. Physicians reported more prioritization in the 20- vs 40-minute visit, indicating that they were likely to discuss fewer services during the shorter visit (median, 5 [interquartile range {IQR}, 3-8] vs 11 [IQR, 9-13] preventive services for patient 1, and 4 [IQR, 3-6] vs 9 [IQR, 8-11] for patient 2). Physicians reported similar top 3 priorities for both patients: smoking cessation, hypertension control, and glycemic control for patient 1 and smoking cessation, hypertension control, and colorectal cancer screening for patient 2. Physicians' top 3 priorities did not usually include diet and exercise or weight loss (ranked in their top 3 recommendations for either patient by only 48 physicians [35%]), although these were among the 3 preventive services most likely to improve life expectancy based on the mathematical model.

CONCLUSIONS AND RELEVANCE

In this survey study, physicians prioritized preventive services under time constraints, but priorities did not vary across patients. Physicians did not prioritize lifestyle interventions despite large potential benefits. Future research should consider whether physicians and patients would benefit from guidance on preventive care priorities.

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.

What works and why in the identification and referral of adults with comorbid obesity in primary care: A realist review

Primary care practitioners (PCPs) are well placed to identify individuals with obesity and weight-related comorbidities and to refer them to weight management services (WMS), but this does not often happen in practice. In this realist review, we searched six databases for intervention studies targeted at PCPs to improve the identification and referral of adults with comorbid obesity. Realist analysis was used to identify context-mechanism-outcome (CMO) configurations across 30 included papers (reporting on 27 studies). Most studies used multiple intervention strategies, categorised into: (a) training, (b) tools to improve identification, (c) tools to improve ease of referral, (d) audit/feedback, (e) working in networks/quality circles, and (f) other. The realist synthesis identified 12 mechanisms through which interventions work to improve identification and referral, including increasing knowledge about obesity and awareness of and confidence in WMS among practitioners, improved communication and trust between practitioners and WMS, and higher priority given to weight management among primary care teams. The theory of "candidacy" (a person's eligibility for medical attention and intervention) provided a robust explanatory framework but required refinement: (a) to take account of the different services (primary care and weight management) that patients must navigate to access support; and (b) to acknowledge the importance of wider contextual factors.

Evaluating Ten Top Tips (10TT): Brief Dietary and Physical Activity Counseling in Rural Overweight and Obese Adults

Adults living in rural areas are at greater risk of becoming overweight and obese due to health care disparities. A pre-/postmatched cohort design was used to evaluate a brief weight-loss counseling intervention, Ten Top Tips (10TT), in a rural primary care setting. The rank sum scores for total weight-loss behaviors and the subscales for dietary changes, self-monitoring, physical activity, and psychological coping taken before and 12 weeks after the intervention differed significantly (P = .0001). Ten Top Tips offers rural community clinics an effective weight-loss intervention.