Kristen M Glenister
Christina AR Malatzky
General practitioners (GPs) have a crucial role to play in engaging patients in discussions about overweight and obesity. However, such discussions are currently uncommon. The aim of this study was to examine how GPs in rural areas talk about overweight and obesity with their patients, specifically to identify key barriers to effective conversations.
This study used a qualitative methodology. Semi-structured interviews were conducted with GPs (n = 7) and patients (n = 7) across two rural areas.
Key barriers to effective conversations between GPs and patients about overweight and/or obesity include: uncertainty about appropriate language; lack of time; concerns about compromising mutual trust and rapport; concerns about patient readiness; concerns about patients’ mental health and how this may be impacted by discussing a potentially upsetting and stigmatising topic; and lack of effective and individualised treatment and/or referral options.
The findings suggest that responses to overweight and obesity need to be localised and tailored. Structural-level change is required to enable better responses to overweight and obesity, including multidisciplinary team approaches.
Overweight and obesity are topics of substantive concern in Australia and other industrialised countries. According to current guidelines, 63% of Australians are considered overweight or obese,1 and this figure is predicted to rise to 80% by 2025.2 Overweight and obesity contribute to the risk of, and/or exacerbate, many chronic diseases, including diabetes, heart disease and cancer,3 and higher body mass index (BMI) has overtaken smoking as the leading contributor to the burden of disease in some parts of Australia.4 Rates of overweight and obesity are higher in rural areas.5
Current literature agrees that primary healthcare physicians (general practitioners [GPs] in Australia) are essential to engaging patients in interventions to address overweight and obesity.6 The vast majority (82%) of Australians visit a GP annually;7 thus, GPs are ideally placed to discuss the links between excess weight and health. The National Health and Medical Research Council’s (NHMRC’s) Summary guide for the management of overweight and obesity in primary care promotes discussion, weight and waist measurement or monitoring, and multiple treatment options.8 However, given that only 22% of patients had their BMI recorded in one Australian study,9 monitoring and discussing weight gain may be uncommon in Australian general practice. Consistent with international literature, Australian research highlights a lack of confidence among GPs in having discussions with their patients about overweight and obesity.10 This lack of confidence could perhaps be due to the sensitive nature of the topic, weight-related stigma,11 belief that weight management advice is futile,12 and/or a lack of training and resources.13
This study was inspired by the results of a recent large-scale community health survey distributed to four regional areas of Victoria.14 This survey found that while 30% of the 1232 respondents were considered obese according to the World Health Organization (WHO) classification system,15 28% had not been diagnosed as such, and less than half had been advised to lose weight by their GP.14 This prompted us to examine how GPs in rural areas talk about overweight and obesity with their patients. Specifically, interviews with GPs and patients were undertaken to identify key barriers to effective conversations related to overweight and obesity between patients and GPs in rural areas, from the perspectives of both of these groups.
Semi-structured interviews were undertaken with GPs and patients located in two of the four regional Victorian locations of the preceding community health survey (populations of 50,000 and 27,000, each with nine general practices).14 The aim was to identify key barriers to effective conversations related to overweight and obesity between GPs and their patients. To recruit GPs, a plain language statement explaining the project was sent via email to all general practices in the two towns. GPs who were interested then contacted the researchers directly. Patients were recruited via a flyer outlining the project, which was displayed in several public places, including gymnasiums, health clinics and public service noticeboards. A total of seven GPs and seven patients across the two sites participated in audio-recorded, face-to-face interviews with one researcher (sociologist or biomedical scientist). Participants were asked about:
- how often weight is discussed during consultations
- how discussions are initiated
- what kind of advice is provided
- barriers to effective conversations.
The resulting data were then coded separately by each researcher for thematic analysis.16 Researchers shared and discussed the initial coding of data before engaging in an iterative process of re-coding, categorising and identifying broad themes.17 Approval to conduct the research was granted by the University of Melbourne’s Human Research Ethics Advisory Group (reference number: 1545331.2). Signed consent was obtained from each participant.
Factors influencing effective discussions regarding overweight and obesity were thematically analysed. Barriers identified included:
- lack of effective treatment options
- uncertainty about appropriate language
- lack of time
- concern about patient readiness
- patients’ mental health.
The extent to which GP participants considered overweight and obesity to be relevant to other health issues experienced by patients was also found to be important to how weight was discussed. Further, it was found that routine weight measurement was uncommon. Mutual trust and rapport were identified as enablers. These themes are explained individually below with supporting data for illustrative purposes.
Lack of effective treatment options and uncertainty about appropriate language
Patients could recall occasions (sometimes decades previously) when a health professional had offended them when speaking about overweight. Correspondingly, GPs spoke about the risk of offending patients when discussing weight issues, a lack of tools to provide support to patients to lose weight, and the need to understand the language that patients prefer when discussing weight.
In terms of the medical tool box, pneumonia: we have a tool for that, diabetes: we have a tool for that … for obesity: we’ve got nothing. – GP 2
When we see someone with ischaemic heart disease, hypertension, depression, we have tools to use to give extra support to these patients, now we need a tool to use to give extra support to the overweight and obese patients. – GP 1
[Cardiac specialist told the patient they were fat] that was so insensitive so that’s when the patient came and said [that they would not go back to that specialist] – GP 4
It was nasty! [The GP said] ‘Do you want to see your kids grow up?’ It was quite harsh! I broke down in tears. – Patient 3
I remember this one explicitly [10 years ago], the anaesthesiologist … she was quite rude about my weight … she said I was lazy … I didn’t even know this person, I don’t see why she had the right to even start commenting. – Patient 5
Lack of time during consultations
Patients expressed that a lack of time during general practice consultations was a barrier to initiating and having in-depth conversations about overweight or obesity. These patients described how restrictive time slots can result in the dismissal or downplaying of weight-related issues. These views were consistent with those of the GPs, who considered lack of time during consultations as an important barrier to conversations about weight and specific weight loss advice – something that patients considered vital.
I said ‘I wouldn’t mind having a chat with someone about my weight’, and she [GP] said ‘We’ll talk about it later’, because everything’s always rushed. – Patient 1
He didn’t give me specifics, no saying eat A, B, C to lose this much weight. – Patient 4
She [GP] said ‘You’ve just got to be aware of what you eat’, which is very easy to say … she didn’t really discuss it. – Patient 5
He [GP] didn’t tell me anything new! – Patient 4
I don’t have the time to give them very specific advice. – GP 1
It’s not a small subject, it is related to everything in their life … you cannot explain this in a 10-minute appointment. – GP 1
Impact of rurality on difficult conversations
GPs spoke about the context of rural practice, which, according to accounts, has both beneficial and detrimental effects on weight-related conversations.
I am a believer that you’re more likely to get appropriate care if you have an understanding of each other … but I can also see that you can become ‘blinkered’ and in a small town, you know them as the plumber or the butcher … so it was harder like within a friendship saying something about weight. – GP 3
I feel like I have a responsibility to this community [to address the issue of overweight and obesity]. – GP 4
Importance of mutual trust and rapport for weight-related conversations
GPs and patients discussed the importance of mutual trust and respect in facilitating effective conversations regarding weight.
I can talk to her [GP] about anything … they [regular GPs] get to know you regardless of what your bad habits are, and you build up a rapport. – Patient 2
You get familiar with the person, you could walk in there and feel confident. – Patient 4
Concern about patient readiness
GPs spoke about the importance of ‘targeting’ particular patients – those who are ready to discuss weight loss. GPs expressed that the ideal discussion required preparation and recognition of the right time. However, some GPs reported difficulties assessing patients’ readiness or encouraging readiness.
[Patients need to be] kind of ripe and ready not just, you know, continuous, ‘Here’s what I think you should do’. – GP 3
I can talk ‘til I’m blue in the face about the health benefits of losing weight, I have no idea how to get people started on that journey. – GP 2
It would be incredibly good to have a comfortable way of asking people if they would like to receive some help with their weight. – GP 2
He was definitely talking to me about that [sudden, large weight gain], but I didn’t want to listen. – Patient 7
Patient’s mental health and impact of stigma
Most GPs interviewed recognised that overweight and obesity are complex social phenomena that cannot be discussed in isolation from other dimensions of the human experience, including mental health. Further, GPs were conscious of the social stigma attached to overweight. However, patients rarely raised these issues.
A lot of people have that stigma: I’m obese, I’m big and actually people don’t like the word obese … there’s a taboo. – GP 4
It [problem with weight] is just like an addiction, most of the people who have addiction because they have some other psychological thing that is leading them to that addiction. Treating the addiction is nothing if you are not treating the factors that are causing the addiction; the addict will go back to it. – GP 1
Depending on their mental health, so if somebody’s a bit um, if they’re fragile you certainly wouldn’t be bringing up about their weight. – GP 5
It is an enormous mental health issue … it’s what is going on in here [the mind] that is probably the most important bit. – GP 2
Lack of effective and individualised treatment and/or referral options
Patients and GPs spoke of the need for evidence-based, effective and individualised weight-loss programs that take into consideration mobility issues, comorbidities, age and financial circumstance. GPs and patients expressed frustration with currently available referral options.
I tailor to individual people because I know my patients well, I know that some like a different way of handling that and so you can’t generalise this problem, you have to really, really individualise. – GP 4
She [GP] could have referred me to the dietician, but then my partner’s gone to the dietician and found him useless. – Patient 5
There is often a long wait to see them [dieticians] and they [patients] don’t seem to get a huge amount of benefit from seeing the dietician. – GP 2
Lack of regular weight measurement
Patients often reported that their GP never weighed them, a sentiment largely echoed by GPs. Patients who were weighed reported that their results were not conveyed to them, not discussed or not discussed in a way that they understood.
She [the GP] weighed me once! – Patient 5
I don’t know how much they weigh, I haven’t weighed them, we don’t weigh, we only weigh children. – GP 2
He [GP] makes a statement: it’s not really a discussion, it’s like ‘You are carrying too much weight’. – Patient 4
… probably get more measurements at the gym from my PT [personal trainer], than I ever did from my GP. – Patient 3
GPs did not automatically equate overweight or obesity with poor health, and this was a factor in deciding whether to discuss weight with overweight or obese patients who were not experiencing weight-related health issues.
There are lots of very healthy obese people, you can be overweight or fat and very healthy, you can be skinny and very unhealthy. – GP 6
I do believe that there are some people who are overweight and still remarkably healthy and actually their weight isn’t really an issue that I need to be too concerned about. – GP 3
This study, by using a qualitative approach to examine the perspectives of patients and GPs, offers an insight into how the issues of overweight and obesity are approached within general practice. Although the research question focused on the impact of rurality on this issue, only a small number of rural-specific issues emerged from the data. The issue of a lack of referral options and specialist obesity services in rural areas were previously identified. One study in rural Queensland reported that GPs overcame limited referral pathways by referring patients to local gymnasiums and fitness classes.18 Other studies have harnessed the strength of social networks in rural areas and have trained lay people to deliver weight loss interventions in their communities.19 Telehealth may provide a solution to GPs (in specialised obesity management support) and patients (in home-based or clinic-based weight management or health coaching).20 Less is known about the impact of rurality on GP–patient rapport and how this affects difficult conversations.
The remainder of the issues identified can be viewed as applicable to Australian general practice more broadly. These issues point to the need for more systemic changes to the way the Australian healthcare system discusses and responds to overweight and obesity.
GP participants appreciated the multidimensional and complex nature of overweight and obesity. GP and patient participants identified a number of barriers to effective discussions about overweight and obesity. Consistent with international literature,13,21 barriers included a lack of time, lack of treatment or referral options, concern about the doctor–patient relationship, patients’ mental health and patients’ readiness.
GPs avoided discussing ‘uncomplicated obesity’, which may mean weight is not discussed at a time-point where intervention is likely to be most effective and may prevent the development of chronic ill health. Weight measurement was not reportedly commonplace, in contrast to measurement of other risk factors such as blood pressure monitoring, which is routine practice. It was found that the rural settings for this study influenced knowledge of social context and interpersonal relationship dynamics between GPs and patients. These influences were both helpful (in sponsoring trust, respect and rapport) and encumbering (difficulty transitioning from a friend to a clinical advisor for a sensitive and difficult issue).
Research, regardless of methodology, is always historically and socially contingent.22 The preconceptions of those involved, including researchers and participants, necessarily inform the research process.22 Thus, it is important for researchers to be reflexive about how context informs the research process. To this end, it must be recognised that the manner of participant recruitment and position of researchers shaped the research presented here. Those who chose to participate in the study were either GPs or patients who had a particular interest in the topic and felt comfortable sharing their experiences with researchers. The researchers also have a particular interest in this topic and their individual positions, like those of the participants, informed the research. This is why the researchers, who have training in different disciplines, discussed their differing perspectives and planned the project, including how data would be analysed collaboratively. Further, given the small number of participants, conclusions that can be drawn from this project must be acknowledged as limited.
Implications for general practice
The findings of this study emphasise the need for responses to overweight and obesity, including referral pathways, to be tailored to enhance available social and recreational supports, especially in rural contexts. The formation of a ‘clinical toolbox’23 could aid in this process, assisting doctors to support patients and gain greater recognition, at the systems level, of the complexities involved in addressing weight-related issues.
GPs, especially those with less experience, may require additional training in conducting sensitive obesity discussions and effective weight-management skills. If weight was routinely monitored and excess weight emphasised as a chronic disease risk factor, GPs may be encouraged to spend a greater proportion of the consultation discussing the issue. Government-led initiatives could assist in addressing obesity as a public health issue, but must avoid fat-shaming and perpetuating the social stigma attached to overweight and obesity.24 The empowerment of local healthcare providers and service systems is likely to assist with the provision of effective weight loss advice and encourage multidisciplinary team approaches.
Kristen M Glenister BSc (Hons), PhD, Research Fellow, Department of Rural Health, University of Melbourne, Vic. email@example.com
Christina AR Malatzky BA (Hons), PhD, Research Fellow, Department of Rural Health, University of Melbourne, Vic
Julian Wright BSc (Hons), MBBS, MSc, MD, FRACP, Professor of Medicine, Head of Department, Department of Rural Health, University of Melbourne, Vic
Competing interests: None.
Provenance and peer review: Not commissioned, externally peer reviewed.
We would like to thank the participants of this study for their contribution. The Department of Rural Health is funded by the federal Department of Health’s Rural Health Multidisciplinary Training Program.
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