Fifteen participants who were obese were recruited from primary care. The interviews were analysed using Thematic Analysis.

        Three themes are presented including ‘Feeling Unsupported,’ ‘Positive Support,’ and ‘the practitioner’s role as a catalyst’. Participants sometimes felt their interactions with their practitioner could be better. The ‘Positive Support Received’ theme showed that participants were positive about the support they received from their practitioner. The final theme shows how participants felt that more direct communication from the practitioner could have helped with the initiation and maintenance of weight loss.

          Communication from the practitioner should be more direct and focused on health outcomes. The practitioner could make use of a ‘teachable moment’ to initiate and influence the motivation and adherence to the weight loss regimen. Practice implications: Practice implications include encouraging an assertive communication from practitioners about the negative consequences of obesity, encouraging more direct communication, and offering support with weight loss.

                      The factors important for weight loss are not well understood [10], few studies have assessed why some people are more successful at losing weight than others [11] and in many cases participants have lost weight as part of a study [12], confounding the conclusions we can draw. Little is also known about the role of the practitioner in what initiates weight loss. In the late 1990s Brink & Ferguson [13] proposed that doctor-patient communication was a main factor that initiated weight loss and more recently, communication from the doctor has also been shown to be effective in achieving weight loss [14-16]. However, further studies have contradicted this, for example, communication has been found not to be important for changing physical activity and fat consumption [17]. Evidence that some practitioners are reluctant to discuss weight with their patients also indicates that this communication may not always occur when it should [18]. Further research has also provided evidence for the impact of life events, including the onset of illness, on initiating weight loss; however, this has also been contradictory. Some studies have shown a positive relationship between life events and weight loss [19-21], some have shown a positive relationship with weight gain [21] while others have shown no impact on weight loss [22]. These contradictory results show there is a lack of clarity on what initiates the change.                        The present study aimed to gather information useful for practitioners in supporting those needing to lose weight by seeking the views of the patients in terms of their experience of weight loss, what initiated their weight loss, what support they found helpful, and what support they would like to receive from their practitioner. In order to capture a wide range of experiences the study recruited a sample with varied experiences with weight loss. Both those who were obese at the time of the study and those who had been obese and who had experienced some successful weight loss (within the last 3 years) were invited to participate. We recruited individuals who were not part of a weight loss intervention as we did not want the results confounded by the fact that the individual was motivated to take part in a research study.

                  Participants were recruited from a United Kingdom National Health Service (NHS) GP practice. Purposive sampling was used to identify participants (by the practice nurse, AH) meeting the inclusion criteria (over 18 years of age, a Body Mass Index (BMI) which classified them as obese within the last three years [3,23,24]. Thirty seven people were invited to participate, sixteen responded positively and one participant withdrew before the interview leaving fifteen participants who took part in the study (see Table 1 for demographic information). The duration of the interviews ranged from 35 minutes to 1 hour and 17 minutes, with a total of 13 hours and 40 minutes of data. Data saturation was achieved as the point was reached where no new themes emerged. The mean age was 58.66 years (range 35- 76), and the mean BMI was 37.94 (mean weight at time of interview 109.40 kg (SD=23.87), range 75-159 and mean weight in last three years 121.88 kg (SD=28.84), range: 94-184). As part of their usual care all participants would have met with the Practice Nurse who used an indirect approach to discussing the subject of weight and suggested keeping a 3 day diet diary before offering advice on their dietary changes. The participants were unknown to the researcher prior to the study (Table 1).

                   A theoretical qualitative design was used to facilitate in-depth data collection into perceptions and experiences of weight loss. Semi-structured (face-to-face) interviews were conducted allowing a flexible exploration of participants’ accounts.

Ethical approval was given by the National Research Ethics Service (NRES) Committee South Central (12/SC/0615) and consent was gained at the time of data collection. The interview schedule was initially piloted on a separate participant to ensure the questions were sensitive and comprehensive. Invitation letters were sent out via the surgery and all the interviews were recorded and transcribed verbatim. The interview schedule covered questions including reasons for trying to lose weight, weight loss experience (and reasons for not dieting), and views on how the practitioner could support weight loss. Thematic analysis, following the steps proposed by Braun & Clarke [25] was used to code and cluster meaning into themes

          Table 2: Master table of themes of obese and previously obese participants’ perceptions of the role of the practitioner in weight loss

Some participants felt that they support they received from their practitioner could have been better. Some felt they could have been supported more and others felt judged because of their weight. For example, the participant below felt blamed for her obesity and the participant’s beliefs about her own lifestyle were at odds with what she perceived their practitioner thought,

                you always get this feeling it is your fault and you don’t know why it is your fault if it is your fault. Yes I can see why someone who sits in a chair all day and eats nothing but junk food and drinks cans of drink, yes, that’s not good for you, but when you lead a perfectly, what I think is a normal life and you still put on weight and the doctors appears very critical and ‘ok, it is your fault, lose some weight’ (Pt 5, 3 kg lost)

               This participant went further to say that she felt like a criminal,

                Doctors make me feel like a criminal. I feel that I am a criminal and that I’ve been … you feel that you’ve been…oh so lax and so you know. I always think what do they think we do all day – do they think we just, just because we are old we sit in a chair and watch the tv and twiddle our thumbs and wait for the next meal to come along, which we have never done (Pt 5, 3 kg lost)

                  The two participants below also felt the support could have been better (Pt 2 and were not satisfied with the support she did receive (Pt 7), Yes, he could have been a lot more supporrtive. It would have made me feel better in myself if nothing else (Pt 2)

        And,

                   I went to my doctor and I said can I have some of these pills [to help lose weight] you know I don’t know what they are called, he knew what they were, yeah, well, he said yes you can, he said but you gotta lose ah a few pounds of weight first, he said, if you go for a week and lose 2 pounds then we will give you the pills to to carry on because you gotta lose the weight first to prove that you can lose the weight. So I didn’t get them because I thought no I am not doing it!… I thought.. then in the end I went to WW, so yeah (Pt 7, no weight loss)

                    The participant below (who had lost 25 kg in the last 3 years) shows how desperate she felts when she remembers that no one told her to lose weight earlier despite her frequent visits to the hospital,

                    I am surprised actually, from me going to visit the doctors, that no one had actually ever mentioned to me that I was overweight and nobody had ever even… and the fact that I see a [clinician], which now it’s all brilliant, it is all good, how are you, you must be feeling great. No one ever said to me at any point ‘do you know you are actually really overweight and would you like us to help you lose weight’ –and the fact that I had been weighed at every appointment, especially at the hospital every little appointment, every three months I get weighed … you didn’t tell me earlier, you know, it really should be because no one close to you is going to say, you know what, you are fat … nothing , nobody said anything. (Pt 10)

                  This final theme was developed from the quotes which indicate what participants felt would have helped them to initiate and maintain their weight loss. When asked how practitioners could help participants offered a range of advice. Participant 1 below recommended a more direct and ‘punchy’ approach,

                Some participants experienced this more direct communication when discussing their deteriorating health, which initiated their weight loss. This news was often received with shock and, faced with their own mortality, initiated behaviour change.

                Participant 9 needed to lose weight for a heart operation and hearing that failure to do so would mean he might not live 10 years brought about a loss of 15 kgs 

                the doctor … he said ‘how old is your little boy?’, ‘he is 9’ and he said ‘well, if you don’t have it [the operation] you won’t see him when he is 19….Yeah oh it [worked] certainly did … yeah. My son is now 27’ (Pt 9)

              Participant 1 shows a lack of awareness on hearing that his diabetes could get worse. At the time of the interview he had lost 19 kgs.

 I never thought the medication was going to step up …   I never thought that it would continue to get worse …that kick started the whole thing so … ignoring it (diabetes) for too long and, and starting to recognise that some of the other symptoms were getting slightly worse. And it wasn’t going anywhere other than the wrong way. (Pt 1) The prospect of having to inject insulin was the trigger for participant 11, losing 14 kgs.

               that was the trigger, that was the trigger, the trigger was, when he gave me the last set of pills he [Doctor] said ‘right that is it, there are no more pills I could give you. After this you are on injections,’ at which I muttered a bit and he said ‘well, you could lose weight because there are people who have managed to fix their diabetes by losing weight.’ Ah, I thought well, I’d better lose some weight, so I lost some weight um……. (Pt 11)

               Not all participants experienced this direct communication and made comments which showed less concern for their health. Participant 5, who had only lost 3 kilograms over the last 3 years, told us her weight loss did not help her health and this appears to have eroded any health motivation that she may have had.

                Yes because the doctor had said about my blood pressure being so high and my aches and pains and they’d be all better, you know, it would get your blood pressure down – it didn’t (laughs) (Pt 5, lost 3 kg)

                Participant 3, who had not lost any weight recently, felt she was not at risk of any negative consequences due to her weight,

                I think basically I am not that worried about it um and so far, I mean I am on blood pressure medications, but so far I’m ok (Pt 3)

and could not see benefits of losing weight,

                I don’t see myself as big as I am and because I just feel so loved, oh, it is ridiculous that, so loved and so happy with what I’ve got I, I don’t see, and I know it would be, but I don’t see that there would be any enhancement to my life [if she lost weight] (Pt 3)

                 With regard to other recommendations, participant 11 suggested pointing out the aspects of life that people will lose if they don’t lose weight,

                 [Doctors could highlight] the loss of things because of this, the loss of some driving freedoms and some sailing freedoms, other freedoms because my diabetes would mean I was down to injecting and I didn’t want to do that um you know, I don’t want to lose a leg (Pt 11, lost 14 kg)

                Comments also focused on tangible help that were mentioned under ‘Support’, for example, their gym or diet-club prescription but also included medication or a gastric band to help with weight loss.

                 f all overweight people were given a gastric band we wouldn’t have half the problems you know and that would be easy, easier than going on a diet being motivated if you were given that (Pt 14, lost 6 kg)

                 well maybe I could you know… is there a a a weight loss drug or something that I could have… (Pt 13, lost 6 kg)  

      More direct communication from the practitioner about their health and weight is partially supported by previous work that showed that serious consequences are associated with the term ‘obesity’ as opposed to indirect references to weight [27]. It is also a difficult role for practitioners who want to be direct but also do not want to be perceived as nagging or being judgemental [18]. Some participants also suggested practitioners use ‘shock’ tactics to encourage people to lose weight. However, the use of shock tactics is controversial as views are mixed and less is known about it in the context of weight loss behaviours. Research in smoking cessation campaigns has shown that shock tactics are not always effective [28,29], however, the context of smoking advertising means it is not tailored advice, as doctor-patient consultation would be. Tailoring the message increases the awareness of the severity and increases feelings of susceptibility so it is likely that the delivery of this information was important in this study. These results should also be viewed with caution as not all people would respond positively to the direct approach and alternative methods of increasing motivation would be necessary.

         Transcending these results is a theme of concordance which pervades all three themes. This highlights the importance of determining where the patient is in their desire to lose weight, the catalyst and the matching support that is needed. Those participants who received a direct communication about their deteriorating health spoke also of the excellent support offered by the practitioner. These participants tended to report weight loss. Some who were less satisfied with their support reported less (or no) weight loss. This highlights the importance of understanding individual patients, the need to use the appropriate strategy to initiate weight loss, and identifying the tailored support. For those who show a lack of motivation to lose weight a more persuasive strategy may be helpful, for example, the use of motivational interviewing (MI) may assist the practitioner here as MI has previously been used with weight loss patients and results have shown both improved motivation and reduced weight loss [30]. Strength of the study was that a varied sample was recruited to ensure that participants had different experiences with weight loss and some had been more successful than others, however, this may mean that motivation to lose weight is also likely to have varied between participants. Another limitation of the study was the self-selected nature of the recruitment meant it was likely to recruit participants who felt comfortable talking about their weight and who had had a positive experience talking to their practitioner about their weight. Future studies should aim to recruit those with negative experiences to ensure a more holistic understanding. Although the sample size was small, data saturation was achieved as the point where no new themes emerged was reached, allowing an understanding of patients’ perceptions. It would also be informative for future studies to include a follow-up phase to track the weight loss maintenance of those who had lost weight.

The results of this study highlight the views of obese participants about the role of the practitioner in initiating and supporting weight loss. These include their role in initiating weight loss and providing tailored support. Other strategies include clear and direct communication from practitioners about the negative consequences of not changing behaviour.

Ethical approval was given by the NRES Committee South Central committee (12/SC/0615). I confirm all patient/personal identifiers have been removed or disguised so the patient/person(s) described are not identifiable and cannot be identified through the details of the story.