Journalof Obesity and Medical Complications

Obese Patients’ Views of the Practitioners’ Role in Initiating and Managing Weight Loss

Bridget Dibb1*, Anne Hardimanb2, Jim WP Roseb2

1 School of Psychology, University of Surrey, Guildford, United Kingdom

2Derry Down Clinic, St Mary Bourne, Andover, United Kingdom

Corresponding author

Bridget Dibb
School of Psychology
University of Surrey
Guildford, United Kingdom
Tel: 44 (0)1483 686866
E-mail: b.dibb@surrey.ac.uk

  • Received Date:19 December 2018
  • Accepted Date:07 February 2019
  • Published Date:09 February 2019

DOI:   10.31021/jomc.20191101

Article Type:   Research Article

Manuscript ID:   JOMC-1-101

Publisher:   Boffin Access Limited.

Volume:   1.1

Journal Type:   Open Access

Copyright:   © 2019 Dibba B, et al.
Creative Commons Attribution 4.0


Citation

Dibba B. Hardimanb A, Roseb JWP. Obese patients’ views of the practitioners’ role in initiating and managing weight loss. J Obesity Med Complications. 2019 Feb;1(1):101

Abstract

Objectives: Obesity rates are increasing and practitioners working in primary care are ideally situated to intervene yet little is known about how the patient experiences this. The aim of this study was to explore patients' perspectives of how practitioners can help initiate weight loss and provide continued support.

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

Results: 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.

Conclusion: 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 Complications: 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.

Keywords

Weight loss; General practice; Patients; Interview; Communication; Obesity

Introduction

Despite the existence of many weight loss interventions for obese people, the incidence of obesity is still increasing [1] and most adults do not adhere to the recommended daily food intake [2]. The General Practitioner (GP) surgery has been identified as a primary area for focusing on managing obesity [3]. However, strategies aimed at managing weight are difficult to evaluate and the still growing rates of obesity (1.9 billion people worldwide were overweight, of which 600 million people obese, in 2014) indicate the causes of obesity are varied and the current strategies are not effective [4-9].

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

Methods

Participants

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 ositively 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).

Design

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.

Procedure

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.

Results

The themes presented below focus on the perceptions of the participants of how they felt the practitioner could support them with their weight loss (see Table 2 for the Master table of themes). The themes show the participants’ perceptions of their interactions with their practitioner, positive support received, and perceptions of the practitioner’s role as a catalyst for their weight loss (Table 2).

Theme 1-Feeling Unsupported

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 supportive. 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)

Theme 2-Positive Support Received

While the first theme focused on aspects that the participants felt could have been improved, this second theme shows how many participants felt they were receiving excellent support. They spoke about the informational support they received, this included the advice they had received and the usefulness of being able to chart their own weight loss, showing that visual information about goal achievement was also useful.

[nurse] always does these charts for me so she can show me where I am and where I am going and maybe (Pt 10, lost 25 kilograms)

And,

the dietician at [name of clinic] has helped me look at what I eat and has sort of helped me with that…I probably had 5 sessions with her um and um and that was really helpful to ah to increase my awareness and it was [nurse] who recommended that I go and look at Nutri check (pt 12, lost 19 kilograms)

Some participants also spoke of the tangible support they received in terms of free gym or weight loss group membership,

[Doctor] is wonderful really because I mean he has given me a prescription for the gym and you know that started me off really, this prescription [for the] leisure centre and they were running this scheme um and I’ve you know that is what got me into it, I’ve quite enjoyed going there (pt 13, lost 6 kilograms)

[nurse] said about the you know the referral where the Drs can refer you for 12 weeks so that is what I am doing but I will definitely keep going afterwards definitely (Pt 14, lost 6 kilograms)

Yes, yes, so I went there [leisure centre] for about 16 weeks to do you know 10 minutes on this and 10 minutes on that, […] the doctor, he paid yeah (Pt 7, no weight loss)

Theme 3-The practitioner's role as a catalyst

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,

Yeah, looking back, they were very nice and they were very diplomatic and they were absolutely wrong in my view of being so damn nice about the situation. I think the GP or people within the health service that I would sit there and say you know what this is what is gonna happen yeah? This is your life; I mean have a discussion, a questionnaire whatever it may be and then the conclusion is ‘if you carry on doing this – that is the outcome, yeah? And you might be fine this year and you might be fine next year but actually that’s not sustainable. And I think they could have been a bit more punchy (Pt 1, lost 19 kg)

Participant 5 also recommended a more direct approach,

Yes, I think you do have to feel good I do think a lot of the time people go to the surgery and the doctor says 'lose weight' and that’s where it ends and normally it's a critical 'YOU NEED TO LOSE WEIGHT' instead of being encouraging and maybe, I don't know how you'd put it, but maybe you really ought to try to lose some weight is there anything we can do to help or, making you feel good about yourself, you know it is not always your fault but if you could try (Pt 5, lost 3 kg)

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.

if 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)

Obesity

Table1: Demographic characteristics

Obesity

Table2: Master table of themes of obese and previously obese participants’ perceptions of the role of the practitioner in weight loss

Discussion

The results show the participants’ perspective of the practitioners’ role in their weight loss. Participants’ views show that some felt that their interactions with their practitioners could have been better. However, others found the support received from the practitioners to be positive. Participants also spoke of what helped them to initiate their weight loss and this highlights strategies for use by the practitioner. Support from the practitioner was another strong theme; participants spoke mostly positively about the support they received. This included visual information about goal achievement, the free gym or diet club membership, a form of tangible support. Tailoring the support to suit the individual is important [26] as one participant did not receive the support she hoped and while she says she joined a weight loss programme this did not result in any weight loss. Some participants suggested more direct and clear communication from the practitioner would be beneficial. Other participants spoke of hearing of their deteriorating health condition, likely to have been told in a direct way, with shock and this resulted in weight loss. Health communication may be a ‘teachable moment’ for the practitioner and communicating news about deteriorating health and lifestyle losses may influence the perceived severity for some participants. This raised awareness of the risks may initiate action to lose weight. The potential importance of communication from practitioners is supported by studies which show that weight loss is more likely when advised to by a doctor [16,17].

The results show the participants’ perspective of the practitioners’ role in their weight loss. Participants’ views show that some felt that their interactions with their practitioners could have been better. However, others found the support received from the practitioners to be positive. Participants also spoke of what helped them to initiate their weight loss and this highlights strategies for use by the practitioner. Support from the practitioner was another strong theme; participants spoke mostly positively about the support they received. This included visual information about goal achievement, the free gym or diet club membership, a form of tangible support. Tailoring the support to suit the individual is important [26] as one participant did not receive the support she hoped and while she says she joined a weight loss programme this did not result in any weight loss. Some participants suggested more direct and clear communication from the practitioner would be beneficial. Other participants spoke of hearing of their deteriorating health condition, likely to have been told in a direct way, with shock and this resulted in weight loss. Health communication may be a ‘teachable moment’ for the practitioner and communicating news about deteriorating health and lifestyle losses may influence the perceived severity for some participants. This raised awareness of the risks may initiate action to lose weight. The potential importance of communication from practitioners is supported by studies which show that weight loss is more likely when advised to by a doctor [16,17].

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.

Conclusion

To conclude, the individual’s perspective shows that the practitioner may have an important role to play in initiating and maintaining weight loss in those who are obese. Participants spoke of the communication and support they received and those who spoke of more direct communication and tangible support were more likely to have lost weight.

Implications for Practice

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

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.

Conflicting Interests

There is no competing interest.

Acknowledgements

We would like to thank our participants for their time and honesty. We would also like to thank Professor Jane Ogden for her feedback on the paper.