Barriers to accessing weight-loss interventions for patients with class II or III obesity in primary care: a qualitative study

Exploring the benefits and costs of a growth mindset in a digital app weight management program

We explored the potential benefits and costs of believing one can change their weight (i.e. growth mindset) in the context of a digital weight management program. We investigated mechanisms by which growth mindsets relate to weight loss achievement and body shame. Among participants seeking to lose weight (N = 1626; 74.7% female; 77.9% White; Mage = 45.7), stronger growth mindsets indirectly predicted greater weight loss achievement through positive offset expectations and subsequent increased program engagement. Additionally, stronger growth mindsets predicted less body shame through positive offset expectations but predicted more body shame through increased onset responsibility, replicating the double-edged sword model of growth mindsets. We conclude with applications that leverage growth mindsets for optimal behavior change while mitigating costs such as body shame.

Research Trends in Motivation and Weight Loss: A Bibliometric-Based Review

Obesity is a complex disease that, like COVID-19, has reached pandemic proportions. Consequently, it has become a rapidly growing scientific field, represented by an extensive body of research publications. Therefore, the aim of this study was to present the research trends in the scientific literature on motivation and weight loss. Because traditional knowledge synthesis approaches are not appropriate for analyzing large corpora of research evidence, we utilized a novel knowledge synthesis approach called synthetic knowledge synthesis (SKS) to generate new holistic insights into obesity research focusing on motivation. SKS is a triangulation of bibliometric analysis, bibliometric mapping, and content analysis. Using it, we analyzed the corpus of publications retrieved from the Scopus database, using the search string TITLE-ABS-KEY((obesity or overweight) and "weight loss" and motiv*) in titles, keywords, and abstracts, without any additional inclusion or exclusion criteria. The search resulted in a corpus of 2301 publications. The United States of America, the United Kingdom, and Australia were the most productive countries. Four themes emerged, namely, weight loss and weight-loss maintenance through motivational interventions, lifestyle changes supported by smart ICT, maintaining sustainable weight with a healthier lifestyle, and weight management on the level of primary healthcare and bariatric surgery. Further, we established that the volume of research literature is growing, as is the scope of the research. However, we observed a regional concentration of research and its funding in developed countries and almost nonexistent research cooperation between developed and less-developed countries.

Culturally adapting an evidence-based intervention to promote a healthy diet and lifestyle for Yup'ik Alaska native communities

Underserved populations are at increased risk for obesity and related cardiovascular disease, type 2 diabetes, and other chronic diseases. Lack of access to healthy foods, sedentary behaviour, and other social environmental factors contribute to disease risk. Yup'ik Alaska Native communities are experiencing lifestyle changes that are likely to affect their cardiometabolic risks. Barrera & Castro's Cultural Adaptation Framework was used to adapt an evidence-based intervention (EBI) originally designed for Latino communities for use in Yup'ik communities. Focus groups and key informant interviews were held in two Yup'ik communities. Major themes included causes of obesity, barriers and facilitators to healthy foods and physical activity, and intervention ideas. The adaptation process was guided by a Community Planning Group of Yup'ik women and included information gathering, preliminary adaptation design, preliminary adaptation tests, and adaptation refinement. Two of the adapted educational modules were pilot tested. Involving community members as co-researchers in cultural adaptation is vital for an EBI to be effective in another population. Small group gatherings led by local lay health workers are culturally appropriate and may be an effective health promotion model in Yup'ik communities. Social environmental factors affecting healthy food availability and physical activity need further exploration.

Barriers and Motivators to Weight Loss in People With Obesity

INTRODUCTION

Obesity has become a global public health challenge with associated health risks. Effective weight-loss interventions are crucial to mitigating these risks and improving overall well-being. However, individuals with obesity often encounter various barriers that hinder their weight loss efforts, while specific motivators can drive them towards successful outcomes. This systematic review aimed to explore the barriers and motivators to weight loss in people with obesity.

METHODS

A literature search was conducted using relevant keywords in electronic databases such as PubMed, Medline, PsycINFO, and Google Scholar. Studies published in peer-reviewed journals during the last 10 years were considered for inclusion. We included studies investigating both barriers and/or motivators to weight loss published in English.

RESULTS

The findings showed that motivators for weight loss include health concerns, body satisfaction, family support, normalcy restoration, emotional encouragement, self-determination, and mindful food choices. Motivators involve exercise facilities, balanced diets, and assistance from healthcare providers, peers, friends, or family. Gender influences healthcare providers' influence on weight loss, with women trusting providers more while men lean towards medication options. Healthcare providers play a role in impacting weight loss through discussions and educating patients. Age also influences motivators; adolescents emphasize health, self-esteem, and bullying avoidance, while young women focus on lifestyle influence, resources, and joy. Barriers include insufficient self-control, physical pain, time constraints, dietary restrictions, and a lack of support. Logistical issues, patient readiness, healthcare providers' views, resource scarcity, and social dynamics are also barriers. Dietary barriers involve triggers, emotional states, and limited healthy options. School-aged children with obesity face curriculum challenges and resource scarcity.

CONCLUSION

These findings show the intricate interplay between motivators and barriers, underscoring the multifaceted nature of weight loss in people with obesity. Targeted interventions that address these factors holistically are essential for successful weight management.

Attitudes of primary care physicians toward bariatric surgery: a free word association networks analysis

BACKGROUND

Primary care physicians (PCPs) hold major responsibility in referring patients with obesity eligible for bariatric surgery (BS).

OBJECTIVE

The aim was to explore PCPs' mental representation of BS in order to identify barriers and catalysts of BS referral practices.

SETTING

Switzerland.

METHODS

A total of 3526 PCPs were invited to participate in an online survey. PCPs were asked to write the first 5 words that came to their mind about the term "bariatric surgery." Additionally, they had to pick 2 emotions that best described each provided association. Demographic data and obesity-related referral patterns were collected. Mental representation network was constructed based on co-occurrence of associations, using validated data-driven methodology.

RESULTS

In all, 216 PCPs completed the study (response rate: 6.13%). Respondents were aged 55 ± 9.8 years, had an equal sex distribution, and practiced mainly in urban settings. Three mental representations of BS emerged: indication-focused (most frequent associations: "obesity," "diabetes"), treatment-focused ("gastric bypass," "weight loss"), and outcome-focused ("complications," "challenging follow-up"). The emotional label "interested" was used significantly more frequently in the treatment-focused group. Comparison of PCPs among mental modules showed that those with a treatment-focused mindset referred patients for BS most frequently and were significantly more willing to follow up with postbariatric patients (χ2 = 17.8, P = .022).

CONCLUSIONS

PCPs think about BS along 3 mental representations, and the treatment-focused attitude was coupled with the highest willingness to refer eligible patients for BS. Confidence in performing postbariatric follow-up was identified as catalyst of BS referral. Access to optimal care for patients with obesity may be improved accordingly.

Primary care providers' perceived barriers to obesity treatment and opportunities for improvement: A mixed methods study

BACKGROUND

Primary care patients with obesity seldom receive effective weight management treatment in primary care settings. This study aims to understand PCPs' perspectives on obesity treatment barriers and opportunities to overcome them.

STUDY DESIGN

This is an explanatory sequential mixed methods study in which survey data was collected and used to inform subsequent qualitative interviews.

SETTINGS AND PARTICIPANTS

PCPs who provide care to adult patients in an academic medical center in the Midwestern US.

METHODOLOGY

PCPs (n = 350) were invited by email to participate in an online survey. PCPs were subsequently invited to participate in semi-structured interviews to further explore survey domains.

ANALYTIC APPROACH

Survey data were analyzed using descriptive statistics. Interviews were analyzed using directed content analysis.

RESULTS

Among 107 survey respondents, less than 10% (n = 8) used evidence-based guidelines to inform obesity treatment decisions. PCPs' identified opportunities to improve obesity treatment including (1) education on local obesity treatment resources (n = 78, 73%), evidence-based dietary counseling strategies (n = 67, 63%), and effective self-help resources (n = 75, 70%) and (2) enhanced team-based care with support from clinic staff (n = 53, 46%), peers trained in obesity medicine (n = 47, 44%), and dietitians (n = 58, 54%). PCPs also desired increased reimbursement for obesity treatment. While 40% (n = 39) of survey respondents expressed interest in obesity medicine training and certification through the American Board of Obesity Medicine, qualitative interviewees felt that pursuing training would require dedicated time (i.e., reduced clinical effort) and financial support.

CONCLUSIONS

Opportunities to improve obesity treatment in primary care settings include educational initiatives, use of team-based care models, and policy changes to incentivize obesity treatment. Primary care clinics or health systems should be encouraged to identify PCPs with specific interests in obesity medicine and support their training and certification through ABOM by reimbursing training costs and reducing clinical effort to allow for study and board examination.

Using Administrative Data in Primary Care to Evaluate the Effectiveness of a Continuing Professional Development Program Focused on the Management of Patients Living With Obesity

INTRODUCTION

There are guidelines for referral to medical and/or surgical weight loss interventions (MSWLI) in Ontario; however, only about one-third of eligible patients in our region are being referred for consideration of MSWLI.

METHODS

A planning committee, including a registered dietician, psychiatrist, endocrinologist, bariatric surgeon, family physician, and educationalists, developed an interdisciplinary continuing professional development (CPD) program focused on practical approaches to the management of patients living with obesity. The Kirkpatrick model was used to evaluate the educational outcomes of the CPD program specifically focusing on Level-2, -3, and -4 outcomes based on self-reported questionnaire and health administrative data.

RESULTS

Eighteen primary care providers from the CPD program agreed to participate in this study, and 16 primary care providers (89%) completed the postintervention questionnaire and granted us access to their MSWLI referral data; 94% of study participants reported changes to their knowledge, comfort, and confidence (Level 2), as well as expected change in their future behaviour (Level 3) following the CPD program. However, there was no change in Kirkpatrick Level-4 outcomes, despite more than 90% of participants indicating that they will be making changes to their practice after the program.

DISCUSSION

The CPD program in our study was overwhelmingly well received and participants reported knowledge (Level 2) and behavioural (Level 3) changes following participation; however, there was no detectable change in their clinical practice (Level 4). The methodology described in our proof-of-concept study can be modified and adopted to evaluate Level-4 outcomes in other studies of effectiveness of CPD interventions.

Self-withdrawal from scheduled bariatric surgery: Qualitative study exploring patient and healthcare provider perspectives

The objective of the study was to explore the experience of patients who self-withdrew from their scheduled bariatric surgery (BS) after completing the lengthy multidisciplinary assessment and optimization process, and to examine how these withdrawals affect healthcare providers (HCPs) in a Bariatric Centre of Excellence (BCoE). Interviews were conducted with patients who self-withdrew, within 1 month, from scheduled BS. Additionally, a focus group with HCPs from the same BCoE was completed. The data were analysed using an inductive, emergent thematic approach with open coding in NVivo 12, with comparative analysis to identify common themes between groups. Eleven patients and 14 HCPs participated. HCPs identified several behavioural and logistical red flags among patients who self-withdrew from scheduled BS. Patients and HCPs felt the decision was appropriate, owing to a patient's lack of mental preparedness for change, social supports, or fears of postoperative complications. HCPs reported frustration and described negative impacts on clinic efficiency. Additional mental health resources for patients contemplating self-withdrawal, such as peer support, were suggested. In conclusion, a patient's decision to self-withdraw from a scheduled BS is often sudden, definite, and associated with anxiety, fear of surgical risks and post-operative complications. Additional mental health resources at a BCoE may be beneficial to support patients at risk of self-withdrawal from scheduled BS.

Integrated Care Model of Adiposity-Related Chronic Diseases

PURPOSE OF REVIEW

Although obesity is a disease, most patients with obesity do not undergo effective treatment nor adhere to long-term care. We examine the barriers that patients with obesity confront when searching for effective treatment and propose an integrated care model of adiposity-related chronic diseases in a cardio-renal metabolic unit.

RECENT FINDINGS

The current care of obesity is fragmented between primary care providers, medical specialists and metabolic bariatric surgeons with little or no coordination of care between these providers. The current care of obesity heavily focuses on weight loss as the primary aim of treatment thereby reenforcing the weight stigma and turning patients away from effective therapy like metabolic bariatric surgery. An interdisciplinary cardio-renal metabolic unit that, besides weight loss, emphasizes prevention/remission of adiposity-related chronic diseases may deliver thorough and rewarding care to most patients with obesity.

Bariatric Surgery and Cardiovascular Outcomes in Patients With Obesity and Cardiovascular Disease:: A Population-Based Retrospective Cohort Study

BACKGROUND

Bariatric surgery has been shown to significantly reduce cardiovascular risk factors. However, whether surgery can reduce major adverse cardiovascular events (MACE), especially in patients with established cardiovascular disease, remains poorly understood. The present study aims to determine the association between bariatric surgery and MACE among patients with cardiovascular disease and severe obesity.

METHODS

This was a propensity score-matched cohort study using province-wide multiple-linked administrative databases in Ontario, Canada. Patients with previous ischemic heart disease or heart failure who received bariatric surgery were matched on age, sex, heart failure history, and a propensity score to similar controls from a primary care medical record database in a 1:1 ratio. The primary outcome was the incidence of extended MACE (first occurrence of all-cause mortality, myocardial infarction, coronary revascularization, cerebrovascular events, and heart failure hospitalization). Secondary outcome included 3-component MACE (myocardial infarction, ischemic stroke, and all-cause mortality). Outcomes were evaluated through a combination of matching via propensity score and subsequent multivariable adjustment.

RESULTS

A total of 2638 patients (n=1319 in each group) were included, with a median follow-up time of 4.6 years. The primary outcome occurred in 11.5% (151/1319) of the surgery group and 19.6% (259/1319) of the controls (adjusted hazard ratio [HR], 0.58 [95% CI, 0.48-0.71]; P<0.001). The association was notable for those with heart failure (HR, 0.44 [95% CI, 0.31-0.62]; P<0.001; absolute risk difference, 19.3% [95% CI, 12.0%-26.7%]) and in those with ischemic heart disease (HR, 0.60 [95% CI, 0.48-0.74]; P<0.001; absolute risk difference, 7.5% [95% CI, 4.7%-10.5%]). Surgery was also associated with a lower incidence of the secondary outcome (HR, 0.66 [95% CI, 0.52-0.84]; P=0.001) and cardiovascular mortality (HR, 0.35 [95% CI, 0.15-0.80]; P=0.001).

CONCLUSIONS

Bariatric surgery was associated with a lower incidence of MACE in patients with cardiovascular disease and obesity. These findings require confirmation by a large-scale randomized trial.

Survey of perceptions and educational needs of primary care providers regarding management of patients with class II and III obesity in Ontario, Canada

BACKGROUND

Primary care providers (PCPs) are typically the primary contact for patients with obesity seeking medical and surgical weight loss interventions; however, previous studies suggest that fewer than 7% of eligible adult patients are referred to publically funded medical and surgical weight loss interventions (MSWLI).

METHODS

We performed an anonymous survey study between October 2017 and June 2018 to explore the knowledge, experiences, perceptions, and educational needs of PCPs in Southeastern Ontario in managing patients with class II and III obesity.

RESULTS

Surveys were distributed to 591 PCPs (n = 538 family physicians; n = 53 nurse practitioners) identified as practicing in the Southeastern Ontario and 92 (15.6%) participated. PCPs serving a rural population estimated that 14.2 ± 10.9% of patients would qualify for MSWLI compared to 9.9 ± 8.5% of patients of PCPs serving an urban population (p = .049). Overall, 57.5% of respondents did not feel competent prescribing MSWLI to patients with class II/III obesity, while 69.8% stated they had 'good' knowledge of the referral criteria for MSWLI. 22.2% of respondents were hesitant to refer patients for bariatric surgery (BS) due to concerns about postoperative surgical complications and risks associated with surgery. Only 25% of respondents were comfortable providing long-term follow up after BS, and only 39.1% had participated in continuing education on management of patients with class II/III obesity in the past 5 years.

CONCLUSION

The majority of PCPs believe there is a need for additional education about MSWLI for patients with class II/III obesity. Future studies are needed to develop and compare the effectiveness of additional education and professional development around risks of contemporary BS, indications to consider referral for MSWLI, management and long-term follow-up of patients after BS.

Association Between Bariatric Surgery and All-Cause Mortality: A Population-Based Matched Cohort Study in a Universal Health Care System

BACKGROUND

Mortality after bariatric surgery has been previously studied, but cohort selection bias, completeness of follow-up, and collection of confounders have limited the inference of results.

OBJECTIVE

To determine the association between bariatric surgery and all-cause mortality.

DESIGN

Population-based matched cohort study.

SETTING

Ontario, Canada.

PARTICIPANTS

13 679 patients who underwent bariatric surgery from January 2010 to December 2016 and 13 679 matched nonsurgical patients.

INTERVENTION

Bariatric surgery.

MEASUREMENTS

The primary outcome was all-cause mortality, with cause-specific mortality as the secondary outcome. Patients were matched according to age, sex, body mass index, and diabetes duration.

RESULTS

13 679 patients who underwent bariatric surgery were matched to 13 679 nonsurgical patients. After a median follow-up of 4.9 years, the overall mortality rate was 1.4% (n = 197) in the surgery group and 2.5% (n = 340) in the nonsurgery group, with a lower adjusted hazard ratio (HR) of overall all-cause mortality (HR, 0.68 [95% CI, 0.57 to 0.81]). Patients aged 55 years or older had an absolute risk reduction of 3.3% (CI, 2.3% to 4.3%), with a lower HR of mortality in the surgery group (HR, 0.53 [CI, 0.41 to 0.69]). Observed relative effects were similar across sex; however, the observed association in absolute terms was greater in men. Surgery also was associated with lower cardiovascular mortality (HR, 0.53 [CI, 0.34 to 0.84]) and lower cancer mortality (HR, 0.54 [CI, 0.36 to 0.80]).

LIMITATION

The observational design limits causal inference.

CONCLUSION

Bariatric surgery was associated with substantially lower all-cause, cardiovascular, and cancer mortality. The lowered observed mortality of surgery was significant across most subgroups. The largest absolute effects were for men and patients aged 55 years or older.

PRIMARY FUNDING SOURCE

Ontario Bariatric Network.