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Primary care is a key component of medical care delivery and has a role to play in reducing obesity in the United States. The purpose of this study was to explore attitudes and perceptions about obesity in low-income primary care patients and to identify preferences for weight management interventions from the patient and healthcare provider perspectives.
A convenience sample of 28 patients and 6 healthcare providers from across the state of Louisiana participated in 1 of 5 structured focus groups. Demographic information was collected from both the patients and healthcare providers using survey instruments.
Patients and healthcare providers were more similar than dissimilar in their perceptions of obesity in that both groups selected referral to a nutritionist, use of medication, and prescribed exercise as the top 3 strategies that would have the greatest impact on losing weight. Referral to a nutritionist was selected as the easiest strategy to implement.
Receiving feedback from both patients and healthcare providers gives researchers the opportunity to acquire useful knowledge that may be beneficial in designing and conducting interventions suitable for patients desiring to lose weight, especially those in primary care settings.
Obesity, defined as having a body mass index (BMI) ≥30 kg/m2, affects 36% of the United States adult population.1 Despite the numerous health concerns associated with obesity, there is some evidence that mortality rates may not increase significantly until levels of obesity >35 kg/m2 are achieved.2 However, obesity in midlife is associated with decreased life expectancy even in the absence of concomitant chronic diseases such as diabetes, hypertension, and coronary artery disease.3-5
While the high levels of obesity are of great concern, a greater concern is that our healthcare system has failed to deliver medical interventions capable of producing even modest weight loss.6 We know that modest weight loss is achievable in some settings; however, this achievement has not been successfully translated to primary care practices.7,8
Primary care practitioners (PCPs) are the cornerstone of medical care in the United States. The U.S. Preventive Services Task Force recommends that physicians offer intensive multicomponent behavioral interventions to obese individuals,9 and the Centers for Medicare and Medicaid Services (CMS) provides coverage for intensive behavioral therapy for obesity by a qualified PCP.10 A recent review indicated that obesity treatment options delivered in primary care have resulted in limited success, demonstrating only 1-3 kg (about 1%-3% of baseline weight on average) weight loss during 6-24 months of intervention.7 The authors concluded that this low weight loss is likely due to the low intensity of the interventions, as most studies typically only employed monthly or quarterly visits of 10-15 minutes' duration.7 Thus, further research is required to develop sustainable, evidence-based models of obesity treatment in primary care.
Obesity disproportionately affects minorities and people with low socioeconomic status,11-13 many of whom receive healthcare in university-based public hospital primary care clinics.13 Important aspects of improving preventive care in primary care clinic settings are to identify patients' knowledge and attitudes about weight loss in this environment and to determine healthcare providers' approaches to weight loss. Therefore, the purpose of this study was to determine the perceptions of obesity treatment options from a patient and healthcare provider perspective. This information is important for the design and implementation of weight loss interventions in healthcare settings.
Patients as well as physicians or nurse practitioners (collectively referred to here as healthcare providers), aged 20 years or older, willing to provide written informed consent and able to speak and understand English were eligible to participate in 1 of 5 structured focus groups held across the state of Louisiana. We did not impose an a priori inclusion criterion based on BMI; rather we solicited participants with an interest in discussing weight loss and weight management strategies. Individuals with a cognitive impairment that would interfere with participation in a group discussion and those who were unable or unwilling to provide informed consent were not eligible.
Participants were recruited by word of mouth or from flyers posted within primary care clinics. Written informed consent was obtained when participants arrived and prior to the start of each focus group discussion. Light refreshments were provided, and each participant received a $50 gift card. The study protocol, procedures, and consent form were reviewed and approved by the Pennington Biomedical Research Center's Institutional Review Board.
The nominal group technique (NGT), a qualitative method of data collection, was used to engage patients and healthcare providers to obtain their perspective on potential obesity treatment strategies. NGT is a brainstorming tool for quality improvement and highly structured small group discussions that is used to elicit and prioritize a list of answers to a specific question.14-18 Similar to traditional focus groups, 4-12 participants per group are considered appropriate for NGT sessions.19
The multistep NGT design is useful for systematically stimulating meaningful interpersonal statements among participants by gathering equally weighted responses to a specific question that tends to offer valid representation of group views.20-23 The NGT method eliminates the need for audio recording and transcription because verbatim responses are written on a flipchart, thereby providing a concise summary of the session that is readily available for dissemination. Prior to conducting NGT sessions, the investigative team articulated the specific question and then pilot tested it with individuals desiring to lose weight to ensure that it would capture the responses intended.
Primary care patients residing in 4 communities (Franklin, Bossier City, New Orleans, and Shreveport, LA) and healthcare providers in Baton Rouge, LA, participated in 1 of 5 NGT sessions. All sessions were conducted during the month of July 2015. Each group consisted of 6-8 participants and included both males and females. All patient sessions were conducted on weekdays within a designated area at each primary care clinic. The healthcare provider session was conducted on a weekday after normal working hours at the Pennington Biomedical Research Center. Each group session lasted approximately 90 minutes.
After welcoming the participants and providing brief introductions, the purpose of the session and ground rules for participation were discussed. Preliminary probing questions were discussed, including “How do you define overweight?” “What are the main reasons that you would want to lose weight?” “What are the best ways to lose weight?” “What are the major things stopping people from losing weight in your community?” and “If researchers were successful in designing a weight management program, what would that look like?”
The facilitator, accompanied by a co-facilitator, then posed the main question to patients: “What has your doctor or other healthcare professional (nurse, etc) done to try to help you lose weight?” Similarly, the healthcare providers were asked, “What are the main things that you have done to help patients lose weight?”
The participants were asked to work silently and to independently write down as many responses to the question as possible in short phrases that represented their individual views. In a round-robin manner, the participants were then asked to share their answers (one response at a time), while the co-facilitator wrote each response verbatim on a flipchart without discussion. Each recorded response was then discussed for the sole purpose of clarification and not for evaluation or debate as to its relative importance. During this step, the participants were asked to combine responses they perceived to be significantly similar. Finally, during the voting phase, the patients and healthcare providers privately selected what they considered to be the top 3 responses likely to have the greatest impact on losing weight. They then ranked the top 3 responses that would be the easiest to implement for weight management.
Each patient and healthcare provider prioritized his/her choices individually without discussing them with others, assigning a rank of 3 to the most impactful and 1 to the least impactful strategy and likewise for the easiest to implement strategy. The facilitator recorded the votes on the flipchart in front of all participants and then tallied the votes for each response. A small number of idiosyncratic ideas were discarded, which is a standard procedure in the NGT. The primary results were the top 3 strategies identified in each group; the secondary results were all other ideas. Through an iterative process, the facilitators categorized responses into common themes until consensus was obtained.
Demographic information was collected from both the patients and healthcare providers using survey instruments that included age, ethnicity, sex, education, employment, annual household income, and marital and health status. In addition, height and weight were self-reported, and healthcare providers selected the number of years in their primary occupation as a physician or nurse practitioner.
Selected demographic characteristics of the 34 focus group participants (28 patients, 6 healthcare providers) are shown in Table 1. Overall, the average BMI for patients was 46.5 kg/m2 (range 30.9-100.4 kg/m2). The overall average BMI for healthcare providers was 26.9 kg/m2 (range 23.4-36.3 kg/m2). Eighty-three percent of the healthcare providers were physicians, and 67% had been in their profession more than 10 years.
Overall, patients defined overweight as having low self-esteem, a reflection of self that does not feel good. Ultimately, the main reasons patients said they want to lose weight are because they are concerned about their health (high blood pressure, diabetes, heart disease), they have family history issues, and they want to have enough energy to keep up with their grandchildren.
Patients consistently stated across all clinical sites that some of the best ways to lose weight are controlling portions (watching calorie intake, reading labels), planning meals, keeping healthy choices (fruits and vegetables) readily available, keeping a food and exercise diary, and joining a social support group for accountability. In addition, patients perceived that a lifestyle change is needed to lose weight because many had taken diet pills and know they work temporarily but that even more weight returns when the pills are stopped. A large number of patients considered diet pills and weight loss surgery as last resorts and options only if absolutely necessary.
The major perceived hindrance to losing weight that patients had in common across all 4 clinical sites was the cost of healthy foods, especially for patients with limited or fixed incomes. Other common barriers included having comfortable and free places to exercise, access to public pools, and the fact that family gatherings center around food.
For researchers to be successful in designing a weight management program, patients commonly reported that the program should be structured and based on individual needs because one size does not fit all. It must also include a support group, enjoyable fun activities, meal preparation (portion control), and exercise (regular and water aerobics) in a comfortable environment.
Healthcare providers defined overweight as greater than the 85th percentile on the BMI growth chart and/or elevated BMI, and they said they know it when they see it. Healthcare providers perceived that the main reasons patients want to lose weight are because of appearance, social pressure, or their doctor told them to lose weight. They said the best way for patients to lose weight is to follow a specific plan: eat a low-calorie diet, increase physical activity, limit sugar, limit portion size, and track what they eat.
The most consistent things these healthcare providers have done to help patients lose weight is counseling them on appropriate portion size, advising them to consume foods that are less calorie dense such as fruits and vegetables, encouraging them to read labels to know calorie content, and discussing the comorbidities associated with excess weight. Healthcare providers perceived that the major barriers to losing weight were the influence of family members, seeing discouraging results, lack of access to healthy food choices, staying at different homes, and consuming fast food dollar menu items.
Healthcare providers perceived that a successful weight management program would be multidisciplinary, structured, and easily adaptable as one size does not fit all. It must be available in different locations, incorporate the whole family, and foster sustainable lifestyle changes. Yet they perceived the real issue with healthcare providers is that they do not have enough time to spend with patients; 15-minute visits are not conducive to combating the obesity problem.
Four NGT sessions were conducted with patients. The first NGT session was held at the Franklin primary care clinical site, and 8 patients generated 24 responses to the question “What has your doctor or other healthcare professional done to try to help you to lose weight?” At the other sites, 6 patients in Shreveport provided 12 responses, 6 patients in Bossier City initiated 19 responses, and 8 patients in New Orleans produced 25 responses for a total of 80 responses. During the clarification discussions, patients at each clinical site indicated that many of the responses overlapped and as a result, responses were merged and combined. The final lists included 6, 7, 8, and 8 responses for each clinical site, respectively, for the prioritization exercise. These 29 total responses across the 4 clinical sites were organized into 4 themes identified during the iterative process: referred to exercise, referred to nutritionist, referred to medication, and provided advice only. In Table 2, the themes are listed in bold print with the actual patient responses from each clinical site listed under each theme. The relative importance (in terms of its impact on losing weight) of each patient response at each primary care clinical site is reflected by the total number of votes and the sum of the ranks given to that response as shown in Table 2.
Some of the patients' actual responses to what the doctor or other healthcare professional had done to try to help them lose weight across 4 sites are as follows: “Do exercise.” “Diet plan, juice plus, less salt and sugar.” “Diet pills.” “Encouraged to change portion size, type of food.” “Walk 30 minutes after eating.” “Appetite suppressants; fat burners.”
The top 3 themes that patients identified as having the greatest impact on losing weight were the same at the Bossier City and New Orleans sites: (1) referred to nutritionist, (2) referred to exercise, and (3) referred to medication. At the Franklin site, patients ranked the themes in the following order: (1) referred to exercise, (2) referred to nutritionist, and (3) referred to medication. The rank assigned by patients at the Shreveport site was (1) referred to nutritionist, (2) referred to medication, and (3) referred to exercise.
Comments from patients at the Bossier City and New Orleans sites categorized under the provided-advice-only theme included, “Encouraged me with motivation on how well my health will be and how the changes will improve my life,” and “Encouraged me to do something.” Representative provided-advice-only theme comments from patients at the Franklin and Shreveport sites were “Everything that is wrong with you is because you are obese,” and “Talked to me about losing weight and getting off some medications.” Patients at all 4 sites perceived the provided-advice-only theme as not requiring a vote because many patients conceived these ideas to be equivalent to nothing tangibly received from their healthcare provider.
Patients across the 4 clinical sites, regardless of rank order, selected referred to nutritionist, referred to medication, and referred to exercise as the top 3 ideas likely to have the greatest impact on losing weight. However, when choosing the easiest method to implement, patient responses varied at 2 clinical sites. Patients in Bossier City suggested a support group for motivation and talking about weight, patients in Franklin identified medication referrals, and patients in Shreveport and New Orleans said referrals to a nutritionist would have the greatest impact as well as be the easiest method to implement for patients to lose weight.
In the fifth and final NGT session, 6 healthcare providers generated 19 responses to the question: “What are the main things that you have done to help patients lose weight?” During the clarification discussions, healthcare providers stated that several responses were repetitive, and they were therefore combined. The final list included 9 responses for the prioritization exercise. These responses were organized into 4 themes identified during the iterative process: referred to nutritionist, referred to metabolic medications, referred to exercise, and referred to weight-loss programs. In Table 3, the themes are listed in bold print with the actual healthcare provider responses listed under each theme. The relative importance (in terms of its impact on losing weight) of each healthcare provider response is reflected by the total number of votes and the sum of the ranks given to that response as shown in Table 3.
Some of the responses healthcare providers stated that they had done to help patients lose weight are as follows: “Talk to them about appropriate portion size and portion control.” “Reduce and/or omit sugary drinks.” “Eat more fruits and vegetables and less calorie dense foods.”
The top 3 themes that healthcare providers identified as having the greatest impact on patients losing weight were (1) referred to nutritionist, (2) referred to metabolic medications, and (3) referred to exercise. Healthcare providers also provided responses categorized under the referred-to-weight-loss-programs theme to further assist patients in losing weight: “Counseling, set goals, motivate,” “Discuss comorbidities,” and “Comprehensive and/or commercial weight loss programs.”
Healthcare providers identified referral to a nutritionist as the strategy with the greatest impact and easiest implementation.
The results of this study revealed overall that both patients' and healthcare providers' perceptions of obesity treatments were similar in several instances. For example, during the preliminary questioning, patients and healthcare providers both perceived that the best way to lose weight was to follow a specific meal plan including healthy choices such as fruits and vegetables, to exercise, and to track what you eat. These similarities coincide with previous research in which fruits and vegetables were provided along with a nutrition education component; participants lost an average of 2.0 kg of weight by the end of the study.24 Yet the major hindrance to losing weight perceived by both patients and healthcare providers is either a lack of access to healthy food choices or the costs associated in obtaining these items. Research has shown that U.S. supermarkets today stock an average of 60,000 foods, so people can choose from a vast array of food options.25,26 However, despite all the food options hypothetically available to U.S. consumers, the participants in this study—like those in others—stressed the realities of living on a limited budget and with limited access to healthy foods, especially when fast foods and highly processed foods are perceived to be less expensive and more readily available than fresh fruits and vegetables.25
Patients and healthcare providers commonly reported that if researchers are to be successful in designing a weight management program it must be multidisciplinary, structured, and easily adaptable to individual needs because, as both groups stated verbatim, “one size does not fit all.” Research purports that weight-loss programs generally adopt a one-size-fits-all behavioral model that subscribes to the culture of the dominant majority without attention to the cultural attitudes and preferences of nonmajority members.27-30 In addition, patients perceived that a successful weight management program should include a support group, enjoyable fun activities, meal preparation, and exercise (regular and water aerobics) in a comfortable environment. Healthcare providers further stated that the successful weight management program must be comprehensive and available in various locations, incorporate the whole family, and foster sustainable lifestyle changes. Emerging evidence suggests that the best outcomes derive from multidisciplinary approaches that utilize a broad range of expertise and varied interventions with proven synergy.31
Finally, patients and healthcare providers identified the top 3 strategies having the greatest impact on losing weight as referrals to a nutritionist, medications, and exercise. In fact, patients at 3 clinical sites (Bossier City, New Orleans, and Shreveport) were in agreement with healthcare providers, citing referrals to a nutritionist as having the greatest impact on losing weight. Additionally, healthcare providers and patients at the New Orleans and Shreveport clinical sites identified referrals to a nutritionist as the easiest strategy to implement for losing weight. Research has shown that nutrition/dietary consultation is one of the most useful supplementary services available in clinical practice for weight management.32,33
While patients agreed with some of the ideas generated by the healthcare providers, they indicated that providing advice only does not tangibly assist them in losing weight. Previous research has indicated that patients prefer healthcare providers to give direct and specific recommendations for weight loss, including exercise and diet instructions.34,35 However, as confirmed by participants in this study, many healthcare providers feel that they cannot devote clinical time to weight management when faced with acute and chronic demands to manage disease states and illnesses stemming from diabetes, dyslipidemias, heart disease, and hypertension.36,37 For their part, primary care patients may have a limited understanding of disease-focused care goals and therefore may not always feel that their weight concerns are being thoroughly addressed.35
This study has several strengths. Some advantages to using the NGT include the fact that the weight of each participant's opinion is the same, and process loss seems less likely to occur.38 The highly structured format of the NGT provides an opportunity for group participants to achieve a substantial amount of work in a relatively short period of time. Another advantage of the NGT is the deliberate avoidance of interpretation from a facilitator who has the responsibility to explore but not to interfere with or influence participants in the group.14
NGT also has some limitations: the composition and representativeness of participants may limit the generalizability of the results, training and preparation are required, the discussion is restricted to a single question, and the NGT does not allow further elaboration of other ideas.39 This study is further limited by its convenience sampling of primary care patients at designated clinical sites (Bossier City, Franklin, New Orleans, and Shreveport, LA) and healthcare providers in Baton Rouge, LA.
Although patients and healthcare providers were perceived as being aware of the key elements necessary for losing weight, results from this study highlight the need for healthcare providers to focus on giving specific guidance and instructions to their patients so that patients do not feel that they are simply being given advice. Further, the ideas generated by these patients and healthcare providers may assist researchers in designing and planning sustainable interventions for weight management in primary care clinics across the state of Louisiana.
This research was supported by the Patient-Centered Outcomes Research Institute (PCORI) Contract #OB–1402–10977. Additional support was provided by 1 U54 GM104940 from the National Institute of General Medical Sciences of the National Institutes of Health that funds the Louisiana Clinical and Translational Science Center.
The authors would like to thank Ms. Amina Massey and Ms. Beverly K. Conish for co-facilitating the focus groups and all primary care clinics and their staffs for providing the space and especially for recruiting the patients for the study. Special thanks to all focus group participants in Baton Rouge, Bossier City, Franklin, New Orleans, and Shreveport, LA, for completing this study.
This article meets the Accreditation Council for Graduate Medical Education and the American Board of Medical Specialties Maintenance of Certification competencies for Patient Care and Practice-Based Learning and Improvement.