A qualitative study of GPs' views of treating obesity

INTRODUCTION

The increase in obesity has been well documented and can be attributed to a range of factors such as changes in eating behaviour and exercise patterns, shifts in food production, and an increasingly obesogenic environment designed to encourage overeating and a sedentary lifestyle.1^–3 The management of obesity is problematic with much research showing that although the most complex interventions may produce weight loss, this reduction in weight is often only short term, with many studies showing that weight returns to baseline levels by follow up.4^–5 In the UK most management of obesity happens in primary care, and yet the primary care approach to obesity has been described as uncoordinated and inconsistent.6 Further, some medical experts in the clinical field of obesity and professional bodies in medicine are concerned that health professionals, including GPs, are not taking the issue of obesity as seriously as they should.7 There is also evidence that GPs are negative about their own role in obesity treatment, which, in part, reflects the problematic nature of obesity management. For example, one study of Israeli GPs by Fogelman and colleagues8 found that although GPs believed it was part of their role to advise obese patients on the health risks of obesity, the majority of doctors thought that they had not made any difference in getting their patients to make long-term changes in lifestyle. Similarly, a Glasgow based study by Mercer and Tessier9 reported that doctors generally had ‘little enthusiasm for weight management’. Previous research has also explored GPs' attitudes to individual treatment approaches and have concluded that GPs have reservations about using anti-obesity drugs.9^,10 Surveys show that that only 3% of GPs would refer obese patients for behaviour therapy11 and that only 23% of primary care physicians would refer morbidly obese patients, who met the criteria for surgery, to a surgeon specialising in surgery for obesity.12 In addition, research also indicates that GPs and patients hold different models of obesity, which may be detrimental to its successful management.13

Research therefore shows that while obesity is on the increase, the effectiveness of available treatments remains low. GPs play a key role in the management of obesity and yet show a range of attitudes towards obesity that may have implications for its management. Previous research exploring GPs' beliefs about obesity, however, has mainly used quantitative methodologies and measures that have been devised and operationalised by researchers. Further, they have tended to explore beliefs in the abstract rather than in the context of the day-to-day management of this problem. In light of this and in line with the current focus on primary care as a potential source of obesity management,14 the present study used qualitative methods to explore in depth how GPs feel about obesity within the context of their own attempts at management and their own interactions with obese patients.

METHOD

RESULTS

GPs primarily described the management of obesity in terms of the issue of responsibility. One GP stated that severe obesity was a medical problem that fell within their professional domain and believed that GPs should take responsibility for its management: ‘There is another group of people who are much more seriously overweight … who are either encountering medical problems, or at a high risk of medical problems, and actually probably what we should be taking is a more medical medicalised approach.’ (Dr 5.)

The other GPs, however, felt that obesity was ultimately a problem that had both been caused and should also be managed by the patient themselves. For example they described how patients have unhealthy diets: ‘Because of his lifestyle — he was working in the City — his lunch was fast food and so it was a difficult issue for me.’ (Dr 15.)

And: ‘She is a woman who has had a sort of fairly appalling diet, clueless really about … what a calorie is …’ (Dr 7.)

GPs also described how patients don't recognise the nature of the problem: ‘What I feel is almost a classic response from women who want to lose weight, but are big, is the sort of “but I only eat a lettuce leaf” approach.’ (Dr 11.)

They also described how patients can be in denial: ‘She often presents asking to be referred to physiotherapy for treatment of her ankle, or the chiropodist to have different shoes to make her feel better, and is really avoiding the real issue.’ (Dr 5.)

The GPs therefore stated that obesity was ultimately the patient's responsibility. In contrast, however, they also described how they felt that the patients did not see the problem in the same way and believed that obesity was the responsibility of the doctor. For example, one GP described how patients want to hand control of their problem to the doctor: ‘He wanted me to magic him lighter.’ (Dr 6.)

And similarly: ‘He was looking to what I was going to do about his weight rather than what he was going to have to do about it.’ (Dr 21.)

They also described how patients were reluctant to accept responsibility for their problem and how some attributed their weight to either a medical cause: ‘Usually patients say, “It's in my genes so we're all overweight — we all eat nothing and we're all overweight.”’ (Dr 4.)

Or an external cause: ‘Obesity has become … into this external problem, it isn't a great deal to do with her anymore in a way, but it is a bit like having a housing problem.’ (Dr 5.)

GPs therefore described the issue of responsibility and although they felt that obesity was ultimately the patient's problem, they felt that patients wanted the doctor to take ownership. This conflict resulted in GPs feeling frustrated with their patients' inability to change their lifestyle. For example, one GP described how suggestions for behaviour change are often met with excuses: ‘People start saying they can't do the exercise, because they can't go to the sessions and … then you talk about other options … like going swimming … just something that would … get them started and it feels like it's just too much to ask … And then I end up feeling it isn't possible for them to do it, so I feel annoyed with them for not just doing it.’ (Dr 3.)

Further, although a small minority expressed some faith in the ability to make a difference, for the majority of GPs, this conflict was exacerbated by a general sense that even if they did accept responsibility for a patient's weight, none of the available treatment options were particularly effective. For example, one GP stated: ‘It is a very current major problem and yet as primary care providers we are very ineffective and rather powerless.’ (Dr 18.)

In particular, they were critical of a catalogue of obesity interventions including dietary advice: ‘I'm not a dietician and I don't feel able to monitor their diet properly.’ (Dr 1.)

Comments about anti-obesity drugs included: ‘I think actually, at the moment, that the drugs are only half the story, and that we actually don't have an effective thing to produce weight management.’ (Dr 10.)

One GP was against the option of surgery: ‘Surgery is hugely risky; it gives a really horrible cosmetic effect. It kind of fuels the cosmetic industry. I've never referred anyone for surgery, and I don't think I would.’ (Dr 11.)

The psychological approach was also discussed: ‘Unless they have an eating disorder, I wouldn't really think of involving the psychiatrist or psychologist.’ (Dr 14.)

Living in this state of conflict was particularly uncomfortable for many doctors as they felt that it presented a challenge to their relationship with their obese patients and believed that a good relationship with their patients was central to their role as a GP: ‘I think with any chronic disease … if there is a good doctor–patient relationship then that definitely will help to overcome not just the problem but other surrounding issues.’ (Dr 15.)

Dr 15 also described how he felt after a consultation with an obese patient that had involved offering advice about behaviour change: ‘I felt happy. I felt at least I had given him knowledge … and at least I'm here if he needs to come or needs any help on any other issue.’ (Dr 15.)

The GPs also described a range of strategies that they used to preserve this relationship with their patients. At times this involved offering empathy, an awareness of the stigma associated with being overweight and trying to locate the problem of weight in the broader context of the patients' lives: ‘He came to see me, and there was lots of anger he had about the difficulty with his weight, his problems with his sex life, the fact that other people had died, his dad had died the year before. His brother had learning difficulties.’ (Dr 6.)

And similarly: ‘They've got problem of housing, marriage, children, money, so they've got other sorts of problem.’ (Dr 16.)

GPs also described how they sometimes met the patients' expectations by offering them medication even when they believed that it wasn't the solution: ‘So I was quite relieved after about a month that she came to me, and she said, you know, “let's stop this drug”, because I didn't think it was the right thing for her.’ (Dr 9.)

DISCUSSION