GPs’ attitudes, objectives and barriers in counselling for obesity—a qualitative study

Abstract

Background: Increasing prevalence of obesity worldwide requires providing support for many patients. GPs in particular, as long-term supervisors of patients, are asked to deliver care to those affected.

Objectives: This qualitative study aimed at identifying GPs’ perspectives on counselling overweight and obese patients.

Methods: To that end, semi-structured interviews were conducted in Berlin with GPs regarding their objectives and barriers in overweight care. Fifteen GPs participated; interviews were audio taped, transcribed and analysed using qualitative content analysis.

Results: Analysis showed a differentiated pattern of medical and psychosocial objectives in obesity treatment. Overall, it was seen that GPs wanted to play a relatively passive role in treatment of obesity. In particular, motivating patients was a key goal of primary care consultations; at the same time patients’ lack of motivation was a main barrier to successful treatment.

Conclusions: Care for obese patients is perceived as ineffective and frustrating. Recommended solutions include further education to improve GPs’ communication techniques, e.g. to trigger patients’ motivation.

Key words::

• Obesity
• primary care
• counselling

KEY MESSAGE(S):

• General practitioners want to play a relatively passive role in the management of obesity

• Motivating patients is a key goal of primary care consultations on obesity

• Perceived lack of motivation in patients is an important barrier to successful obesity management by general practitioners

Background

Prevention and treatment of obesity is one task that general practitioners (GPs) face. It presents a challenge for primary health care providers, especially in the context of blame and responsibility. Successful interventions need to consider elevated body weight as a complex phenomenon whose treatment requires extensive changes in lifestyle and behaviour.

GPs, as long-term supervisors of patients, are key persons in long-term treatment of obesity (1,2). Overweight patients tend to see their GP more frequently than patients with a normal body weight do (3,4). The American Medical Association emphasizes the crucial role of GPs in obesity management: Patients are asked to consult their GP first. Only when this strategy fails is it recommended to consult other health care providers such as dieticians or psychologists (5). In Germany, where patients have low-threshold access to all medical specializations, obese patients do not necessarily see their GP first.

In face of this high responsibility, many GPs feel ineffective in weight management of their patients (6,7). Studies have established several barriers perceived by GPs in obesity therapy. GPs reported lack of competencies as well as a lack of reward for this particular task. Furthermore, they reported that addressing the topic of weight to their patients is detrimental to doctor-patient interactions. In their view, reducing overweight is the responsibility of patients and does not primarily require a medical solution (8). Patients in turn ask for medical and external solutions and try to delegate the responsibility to their physicians (9,10). Their perception of GPs as relevant sources of support can in fact be seen as an opportunity to influence patients’ health behaviour.

However, studies also reported GPs’ negative stereotypes towards obese patients. One common prejudice is that they are lazy and undisciplined (11,12). Certain subgroups of overweight patients are less frequently counselled, in particular those with a lower income (13).

Supporting these results, a study by Wadden et al. showed that patients have low confidence in their GP's treatment of obesity, although they were very confident in the general care offered by the same doctor (14). In addition, Ely et al. reported that patients do not feel that their GPs support them adequately in the task of weight management (15).

Due to low success rates, treatment of obesity is often frustrating for both patients and physicians. Development of successful intervention strategies that focus on long-term effects of weight maintenance need to consider patients’ and GPs’ views alike.

This paper aimed at clarifying GPs’ perspectives on their health care offered to overweight and obese patients. Of particular interest was how GPs described their role in care for overweight and obese patients and their main objectives when counselling these clients. Moreover, we analysed whether specific patient characteristics led the GPs to indicate necessity of treatment, how they addressed the topic to their clients and which barriers they perceived.

Methods

Qualitative methodology was chosen, given that it enables acquisition of a broad range of data and a detailed understanding of GPs’ attitudes and objectives in obesity treatment.

Participants

We conducted a cross-sectional study of 15 primary care physicians (GPs) working in solo practices. GPs were recruited by the local board of health in Berlin. Of the 70 GPs invited to participate, 15 accepted. Main reasons for refusing participation were: lack of time, new to practice and low interest in research. We did not offer GPs incentives for participating. 6 male and 9 female GPs were interviewed. Interviews lasted between 37 and 81 min with a mean length of 52 min. GPs had an average age of 51 years. None of the GPs showed an elevated body mass index (BMI) (mean: 22.4 kg/m²).

Qualitative method

Participants were invited to a semi-structured guided interview with predefined questions using mainly open-ended questions and focusing on communication and counselling habits in obesity treatment. The interviews were carried out mainly in the GPs’ practices and were audio-taped. They were transcribed anonymously and subjected to Mayring's technique for qualitative content analysis (16–18). This analysis applies a systematic, theory-guided approach to text analysis using a category system. A central component of the analytical framework is paraphrasing, summarizing and deleting recurring text passages on a predefined abstraction level with stepwise generalization of individual statements in the transcribed interview material. The analysis consisted of identifying categories of individual counselling strategies. Categories are developed near to the material with a focus on weight counselling. Aspects that guided the interview provided the main categories for analysis. A provisional category system was constructed by assigning the codes of the interview analysed at first to the main categories derived from the interview guideline. This category system was refined from interview to interview until congruence with the complete amount of data was reached. With an increasing number of codes more and more subcategories were found to determine the various aspects of the main categories. Each sub-category was attributed to a quotation. Three authors (AB, US and CH) coded the material inductively, focusing on the interviewees’ own views and concerns rather than using a theoretical template or eliciting topics. When ratings of the sample differed, a consensus was reached by a re-evaluation and panel discussion. The investigators agreed on 85% of the initial coding categories and, after discussion, reached a consensus on the final data coding. To facilitate the coding process, the qualitative data analysis software AtlasTi was used. For this publication, quotes from the interviews were translated from German into English and re-translated backwards to German to test conformity. The study was approved by an independent ethic committee. Each GP provided their informed consent to publication of the data.

Results

GPs’ role in obesity therapy

GPs’ attitudes towards counselling overweight and obese patients varied substantially. They did not generally feel responsible for overweight therapy. For the main part, GPs wanted to play a passive role in treatment of obesity and saw themselves as supervisors of weight management, as the following quotation shows:

Today I can say: It is one's own … disease … it's their weight, their cholesterol … and there are possibilities to treat this! Or to live according to certain guidelines. But, if they do not want this, then I take it as it is. (GP1)

However, one GP called himself a 'gathering place’ (GP2) for all health-related complaints and underlined his responsibility for patients’ health.

Only a few of the GPs wanted to play an active role in obesity treatment and guide their patients:

As a GP, I have to make sure that patients come back to me. Not because of the money, but because if they are not under my supervision I haven't won anything! I have to create a situation that encourages the patients to come back to me, even if they did not reach the goals we agreed on. (GP15)

Need to treat

Several medical and nonmedical reasons for treating overweight and obese patients were mentioned by GPs. When deciding whether to counsel and treat elevated body weight, GPs considered patients’ weight and in particular the body mass index (BMI), their visual impression of patients and their assumption of risk factors and co morbidities. Another medical reason named by GPs was prevention of obesity-associated diseases. The nonmedical reasons that GPs cited were demographical aspects of patients (e.g. age), their general impression of patients and patients` requirements.

GPs mainly defined a need to treat as related to an elevated BMI. Patients with a BMI above 30 kg/m² were regularly treated for their body weight, whereas patients with a BMI between 25 kg/m² and 30 kg/m² were treated only if the GPs’ visual impression deemed it necessary. In addition, GPs took into consideration their general perception of a patient when planning interventions.

Hmm, I do not regularly consider their weight objectively instead I consider the visual effect and ... hmm. I address the topic with those who seem to be overweight. (GP3)

A main determinant of GPs’ therapy decisions are obesity-associated diseases, in particular cardiovascular risks.

If I have a patient who is overweight and shows a high blood pressure, extremely high level of cholesterol, etcetera, who is smoking, etcetera … then I would tell him: “It won't work like this! Something has to change!” (GP14)

GPs considered epidemiological characteristics of patients when planning an intervention. The following remark provides an example:

I have a 65-year-old or a 72-year-old sitting there. And then … well … I am not so strict as to say “Look, you urgently have to lose 10 kilos!” and so forth. No! (GP14)

Situations in which the topic of overweight is addressed

GPs named various situations in which they confront their patients with this issue. Some GPs bring up the topic of overweight and obesity spontaneously in consultations. Others address the topic in specific situations, e.g. during a standardized preventive programme, or attempt to introduce the topic via related co morbidities (e.g. knee problems) or acute morbidities (e.g. gastro-intestinal diseases). Some GPs offer extra appointments to talk more intensively about elevated body weight, as the following quotation shows:

If you'd seen my practice this afternoon, where we had to deal with 60 patients, it would be clear that I cannot conduct any consultations on obesity. But I can offer extra appointments for that purpose. (GP5)

Additionally, some GPs reported that they do not broach this topic in first contacts with new patients. They maintained that it was their priority to build up a reliable relationship first before discussing such sensitive topics.

GPs’ objectives in obesity treatment

Various objectives in counselling overweight and obese patients were identified. Some GPs concentrated on biomedical ones such as prevention of related diseases, weight reduction, general improvement of clinical parameters and reduction in intake of medications. Most GPs, however, reported a combination of medical and psychosocial objectives. Table I provides an overview of psychosocial objectives and exemplary quotations.

Table I. GPs’ psychological objectives in obesity therapy.

Psychosocial objectives	Quotation
Providing of information	‘Well, I want to communicate … hmm … which … risks may occur! For the musculoskeletal system, as well as the risk of diabetes …’ (GP12)
Clarification of individual responsibility	‘Well … I want to kindly point out to the patient that their interest in their own health is very important and that they have to develop their own actions based on this!’ (GP9)
Awareness of the problem	‘Well, the overweight often do not know what risk they carry in their body … in many organs’ (GP12)
Assessment of patients’ views and needs	‘There is an entire person and there is always a reason why a person has such a body weight. That means it makes little sense to talk about weight if there are totally different things in the background that maintain the whole situation.’ (GP 14)
Development of practicable concepts for everyday life	‘To tell them: “Look first at what you could perhaps … hmm … exclude in daily life or that you perhaps stop using lifts or the like!”’. (GP8)
Motivation regarding behaviour change	‘Motivate, motivate, motivate!’ (GP7)

Barriers to obesity treatment

GPs reported several barriers in their consultancies with overweight and obese patients. One central restriction for many GPs was seen in a lack of treatment possibilities due to material and time-related constraints (e.g. patients have to pay for treatment of their overweight)

Well, I cannot handle this on my own … to assist in weight reductions … continuously. That … that's impossible! (GP 15)

The second main barrier perceived by GPs was patients’ lack of motivation and health consciousness.

… Success in therapy is due solely to motivation and anything I do cannot be as successful as that [motivation] … (GP13).

Discussion

The aim of this qualitative study was to investigate GPs’ attitudes, objectives and barriers regarding treatment of overweight and obese patients. GPs’ general attitudes are reflected in their concept of playing a relatively passive role in obesity management. In line with other studies, GPs emphasized the active role of patients in achieving necessary lifestyle changes and see themselves as supervisors of behaviour changes (9). Hence, increasing patients’ motivation was one of GPs’ main objectives. At the same time, lack of motivation was identified as a main barrier for success because patients are perceived as unwilling to be motivated. Quantitative data from Visser et al. support these negative attitudes towards obese patients (19).

GPs focus in their consultations on patients’ motivation to take responsibility for their health. In contrast, patients, especially those with a BMI above 35 kg/m², hope for external and medical solutions to their obesity (9,10). One main means of generating motivation is to apply effective communication techniques. Motivational interviewing (20) as one validated communication strategy was helpful in weight management (21,22). It is suggested that GPs be trained in motivational interviewing techniques and implement these into regular care for overweight and obese patients.

Grief et al. found that GPs with a high level of obesity-specific knowledge are more likely to believe in the success of their therapy. This finding underlines the meaningfulness of further education for primary health care providers who deal with overweight and obese patients (23).

GPs in our sample reported that they treat overweight and obesity rarely as a single condition but mainly in association with cardiovascular diseases. Therefore, standardized prevention instruments (e.g. the Check-up 35) were used as a door to discussing body weight. A common strategy to address the topic is via related laboratory results, which seem to facilitate talks about this delicate issue (24,25). Additionally, guidelines structuring preventive encounters could support GPs in terms of lifestyle counselling.

In line with other studies (26), GPs named several physical characteristics for paying attention to treat obesity; existing co morbidities and the BMI as an established parameter were particularly relevant parameters. According to the guidelines for obesity management, GPs tend to treat patients with a BMI over 30 kg/m² (1,2) and see a BMI between 25 kg/m² and 30 kg/m² as relevant for therapy only if co morbidities exist. However, nonmedical triggers such as GPs’ general impression of patients were mentioned as well. Some GPs reported that they treat obesity only if patients appear to suffer from it.

In sum, our analysis revealed a differentiated pattern of medical and psychosocial objectives in overweight and obesity treatment, which reflects a holistic, patient-centred approach in primary care and is a remarkable strength of GPs’ long-term care. The high demands of this form of care on GPs contrast to the reported lack of time and material available to offer efficient interventions for obesity. Therefore, the implementation of team-oriented rather than GP-centred care models is suggested. To delegate tasks to trained nurses, psychologists and other specialists would lead to an integrative care that could be monitored by GPs. A review of Tsai et al. supports the need for collaborative care in obesity management (27). The authors concluded that low- and moderate-intensity counselling delivered by GPs alone is unlikely to result in clinically significant weight loss. Ely et al. (15) show that patients agree that obesity treatment can be partly delivered by other health professionals but insist on having their GPs regularly involved. This view is consistent with recommendations of guidelines for obesity therapy (1,2), which see the GP as a coordinator between different treatment components.

Strengths and weaknesses

Qualitative data from interviews allowed for deep insight into GPs’ objectives in obesity management. However, committed and highly motivated GPs may be over-reported in our data. Additionally, none of the participating GPs was overweight or obese, which might have influenced results. In particular, GPs who are affected themselves may be less intent on playing a passive role in treatment. This question needs to be analysed in future research.

Qualitative studies are characterized by rich, in-depth topic exploration among small samples. Findings from this study are hypothesis-generating and provide essential leads for further research in this field of obesity management.

Conclusions

Our analysis showed that GPs aim at offering individually tailored, patient-centred therapy to obese patients but face several barriers. These can be combated by an increase of obesity-specific knowledge and training in communication skills as well as an integrative care combining the skills of several health experts such as psychologists and nurses. GPs as long-term supervisors of patients need to play a key role in an interdisciplinary working team. Their task is to coordinate prevention and treatment of obesity, using their advantage of having a long-term relationship with their patients.

Acknowledgements

The authors should like to thank GPs who participated in this project. This work was supported by the Federal Ministry of Education and Research (BMBF—Reference No. 01GWS053).

Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.