People with weight-related long-term conditions want support from GPs: A qualitative interview study

Summary Two-thirds of UK adults do not have an up-to-date weight record in primary care. Some studies suggest that doctors do not raise the topic of weight management for fear of causing embarrassment or offence, or are doubtful whether people will make changes. However, for people with weight-related long-term conditions, conversations with general practitioners (GPs) can be crucial. Our study explores how people with long-term conditions associated with overweight recall and interpret conversations about weight in British primary care. An experienced qualitative researcher interviewed 41 people aged <42 years with long-term conditions associated with overweight. A maximum variation sample was sought, and transcribed interviews were analysed thematically. We revealed that patients with weight-related long-term conditions have different experiences and expectations about the role of GPs in supporting weight management. If a GP did not raise weight management in the context of the long-term condition patients formed the impression that their overweight was not seen as “ doctorable ” that is, as an appropriate topic for the consultation, rather than a personal or “ lifestyle ” concern. This was explained in multiple ways, which are captured in two themes; perceiving weight as “ doctorable ” ; and weight doctoring in primary care. The findings highlight the need for increased attention on weight-related long-term conditions in primary care. Interventions from GPs would be welcome if conducted in a sensitive, non-judgmental manner and based on sound evidence about what works.


| Recruitment
As authorized by the NHS National Research Ethics Committee South Central-Berkshire (Reference: 12/SC/0495), all participants were recruited through GPs, weight-loss clinics, community services, and snowball sampling and approached by telephone, mail, and email. The study aimed for a maximum variation sample. 20 We made efforts to recruit people from different parts of the country, social and ethnic minority background, and history of weight gain, loss, or maintenance.
Experiences of weight and long-term conditions are likely to change over time. Thus, we recruited people whose long-term conditions had been diagnosed recently as well as those who had lived with their conditions for many years.
Participants were provided with information sheets and consent forms explaining the research and given time to decide whether they wanted to take part. These documents introduced MS (name, gender, job role, institution) and explained the reasons for this research. MS, a professional salaried researcher was funded to conduct this research to improve understanding of the experiences of people with longterm conditions associated with overweight and use this understanding to develop resources for information and support. Neither she, nor any of the co-authors, had a prior relationship with any of the participants.
What is already known about this subject?
• There is increasing pressure on primary care to deliver weight-management interventions; yet, two-thirds of UK adults do not have an up-to-date weight record. 1,2 • For people with weight-related long-term conditions, support for weight management can be crucial.
• The experiences of people with long-term conditions associated with overweight in relation to GP care have attracted little interest in the literature.

What this study adds?
• This qualitative interview study included people with weight-related long-term conditions to explore how weight conversations with GPs are recalled and interpreted.
• Those whose excess weight did not seem to be a priority to their GP reinforced the idea that weight-management is not a "doctorable" problem.
• GPs may want to consider offering increased, sensitive, and evidence-based weight intervention support for people with weight-related long-term conditions to underline the message that weight is a priority and that treatment and support are available.

| Interviews
In-depth qualitative interviews were conducted with 28 women and 13 men about their experiences of a weight-related long-term condition by an experienced qualitative researcher (MS, a middle-aged woman with a PhD). One interviewee dropped out due to time commitments. Interviews were conducted in 2018 across the UK in locations chosen by the participants, usually their own homes, although some interviews were conducted in community centres, hotels, or private interview rooms at the University of Oxford. The interviews had two parts: 1. An unstructured narrative where participants described their own experiences, thoughts, and important moments, with minimal interruption, of having a long-term condition associated with overweight; and 2. A series of specific topic questions asked by the researcher to explore issues already raised and potentially salient issues that had not yet been discussed. This section included questions about experiences of using British primary care for weight services and messages for clinicians working with long-term conditions associated with overweight.
With informed consent, interviews were audio-recorded for transcrip-

| Sample
Forty-one people with 36 weight-related long-term conditions were represented in the sample. Recruitment continued until the analytic themes appeared to be fully saturated, and new interviews were no longer adding categories to the analysis. 21 Conditions included arthritis (n = 3), irritable bowel syndrome (n = 1), Type 2 diabetes (n = 17), cancers (n = 3), epilepsy (n = 1), fibromyalgia (n = 1), high blood pressure (n = 5), sleep apnoea (n = 6), multiple sclerosis (n = 1), osteoarthritis (n = 6), and heart conditions (n = 8). Some participants had multiple long-term health conditions. Sixteen participants perceived themselves to be experiencing weight-gain at the time of the interview, with 6 reporting weight-maintenance and 15 reporting weightloss. Two participants did not disclose whether they were in a weight gain, loss, or maintenance stage, and two participants felt that they were plateauing with their weight loss. Nine participants were from the English midlands, 9 from the South of England, 20 from the North of England, and 3 from Scotland.

| Analysis
The interviews were transcribed verbatim and returned to participants to give them an opportunity to revise or remove any sections that they did not want to be used in the analysis. Any such sections were removed before the authors accessed the interviews. Data were then coded by MS using NVivo12. 22

| RESULTS
Our analysis suggests inconsistencies in how GPs support people with weight-related long-term conditions to manage their weight. This was explained in multiple ways, which are captured in two themes; perceiving weight as "doctorable"; and weight doctoring in primary care.
Anonymised excerpts are presented to illustrate these themes.

| Perceiving weight as doctorable
Patients decide which of the health issues they face may be amenable to treatment by their GP-those issues that are considered appropriate to discuss have been described as "doctorable." 26 In many of the accounts, participants mentioned that GPs rarely discussed weightmanagement despite its connection with the long-term conditions that they were experiencing. Many participants struggled to make sense of this absence. A male with sleep apnoea, which he knew was related to his overweight, commented that his GP had never raised Similarly, some participants said they were surprised that their GP had not mentioned their overweight before they developed their weight-related long-term condition. A woman with Type 2 diabetes, for example, explained that her husband was confused about why her GP had not mentioned her overweight. From her husband's point of view, her weight only became doctorable once she had a diabetes diagnosis: "When my periods ceased, I thought, 'Oh it's menopausal,' and I went (to the GP), there was never a comment (about my weight). My husband said to me on a couple of occasions, 'Did they mention your weight?' Not one of them (GPs) had ever mentioned my weight until the diabetes." (P18, F, Type 2 diabetes).
The lack of expected doctoring for weight was variously interpreted; patients primarily suspected that GPs were uninterested, embarrassed, and/or were more interested in treating other conditions rather than overweight: "I have to go to the GP quite a lot, and they don't seem to be interested in my weight… They just say," Oh, we'll treat this or that, do not worry about weight. "I think they're Even when GPs did discuss weight management, some participants reported dissatisfaction. A woman who went to see her GP for a non-weight-related condition described her interaction as "one of the most unsatisfactory experiences" due to the doctor treating her overweight in a "tokenistic way." She explained that the GP asked her only a couple of weight-related questions, which she suspected was to make a good example to a trainee doctor in the room. What stood out to the participant was that the doctoring consisted of dietary advice, despite her expressing that she generally eats healthily other than when she lacked time: "I went (to the GP) with a different problem, she mentioned my weight, and it was one of the most unsatisfactory experi-ences… she had a trainee doctor in the room, and I felt she'd just put that question into our consultation as an example of good practice. I explained that I did eat well, but time was a factor sometimes… She said to me, 'If you make a small change like take a salad to work,' I felt quite insulted. I just felt it was tokenistic, really." (P10, F, multimorbidity).
Although relatively few participants described positive doctoring for weight in the context of their long-term condition, many suggested that discussion of weight was most beneficial when GPs took time to listen and offer person-centred support based on sound evidence about what works. One participant with multimorbidities described his GP's technique as listening and adapting interventions based on his experience. He perceived his GP's advice as "straight" and "sound." A woman with impaired mobility described her experiences as "outstanding." She emphasized that getting the right GP is essential to successful weight doctoring: "My GPs have been outstanding for me… Getting the right GP is the most important because they're your first point of call. We (GP and I) delved into (my condition) and started to find out there were more things wrong with me than I anticipated. But having him… being able to call and say,", Can you ask the doctor to call me?"… And then they do call. It's just nice" (P37, F, impaired mobility). A few participants spoke of success with self-management, mainly discovering what worked through trial and error. For these participants, adhering to self-management techniques involved having the right mind-set or great personal motivation to lose weight: "It's all in the mind. Your attitude does have to change if you want to lose weight". (P09, F, clogged artery). Most of our participants described having this mind-set. However, as described earlier, they often lacked the means to engage with these techniques because of the symptoms associated with their long-term condition.

| Weight doctoring in primary care
The people we talked to wanted different approaches from primary care staff in relation to their overweight: Some wanted overt attention to their weight, whereas others said that weight-management consultations were difficult. However, few participants appreciated simple advice based on "eating less and moving more." A participant with joint hypermobility syndrome said that it was a conversation with a nurse while she was being weighed that caused her to rethink whether she really wanted to have bariatric surgery: "She (the nurse) was weighing me and talking about diet, and it definitely helped. She said if you want to go ahead and get bariatric surgery, you've reached that point.
But then I thought, "Nah, it's not for me." (P04, F, joint hypermobility syndrome). Diet and lifestyle advice is readily available, as this participant notes: "They sent me to a dietician. She was lovely, I knew all that she was telling me, it's all on the television now… she was very good with me, but it wasn't what I needed. I needed counselling." (P07, F, multimorbidity). and they say, 'Well, you're not doing it enough.' There's no alternatives. I think they are given a script…" (P35, F, multimorbidity). This lack of attention to the patient's weight was echoed several times in our participants' accounts, with some suggesting that their GPs were not doing a key part of their job. A man with Type 2 diabetes explained: 'I was lucky, or unlucky I'd got a really nice group of doctors who never made a big deal about it (his weight)" (P39, M, Type 2 diabetes). However, later in his account, he emphasized that he needed a doctor to stress the importance of him losing weight: "If you've got somebody who came up and says, 'You're eating too much.' That's different. It might not make any difference, but you would take note. Whereas if they say, 'Maybe you should try losing a wee bit of weight,' like maybe it was an option. It's not an option. Be brutal and ruthless." This idea of doctors being brutal when discussing overweight was also mentioned by another participant with Type 2 diabetes. This participant suggested that if her doctor had been more direct about her overweight, she would have taken measures to avoid it: "They'd say, 'well, you're a wee bit chubby,' and I was at the time… They never said, 'You're pre-diabetic'… If the doctor had stressed that I would have done something about it… They have to be more brutal." (P08, F, Type 2 diabetes). These last perspectives were atypical, divergent, and cases in our data, and we should note that people may not appreciate

| Summary
This study found that GPs in UK primary care are not perceived to prioritize weight-management discussions even with people with weight-related long-term conditions, a group who could clearly benefit from support in losing weight. Several meanings were attached to why this may be, including perceptions that GPs were embarrassed, uninterested, or more interested in managing symptoms. This puzzled participants who viewed their weight as "doctorable" and knew that their long-term condition was weight-related. They expected weightmanagement advice and treatment but instead said they received mixed messages about the importance of managing their weight from GPs, who rarely spoke about it or offered treatment. Micro-level interactions within consultations, for example, when GPs simply offered diet and lifestyle advice, were also reported to reinforce notions that weight-management is not doctorable. Some felt that their weight was treated in a tokenistic way or that their other conditions were viewed as more doctorable. Those who described positive experiences said their GPs took time to listen and offer personcentred support based on sound evidence about what works and were willing to make adjustments to the treatment/ medicines for the associated long-term conditions.

| Where this fits with other literature
Our findings that GPs may appear to overlook overweight when associated with a long-term condition are supported by a quantitative study of weight measured in electronic health records in the UK 1 and a systematic review of perspectives of people with overweight. 16 Our participants' observation that GPs do not appear to prioritize discussion of overweight is also congruent with several qualitative studies on the views of GPs about weight-management conversations with people who are overweight. 2,8,27 The Awareness, Care, and Treatment In Obesity Management International Observation (ACTION-IO) survey, for example, found that healthcare professionals assumed that people with obesity were not interested or motivated to lose weight. 28 People with obesity, on the other hand, thought that they were making serious efforts to lose weight on their own but were having limited success and needed support and guidance from their GP. 28 However, none of these studies has focussed on weight-related long-term conditions. A recent review of qualitative studies with primary care staff 14 found mixed views about whether there was enough evidence to support GPs to advise people who are overweight (there is). Even among those who did see it as "part of the job" to advise weight-management, some suggested that limited time in the consultation meant that staff prioritized other, more effective, discussions. 14 A recent systematic review of behaviour change conversations in GP consultations also suggests that people can respond negatively to unilateral advice-giving and prefer a collaborative, personalized approach linked to something important to them. 29 The existing literature has highlighted that weight-management conversations should be helpful and supportive, rather than present 'worst-case scenarios. 30 Our findings may be transferable to Canadian and American primary care settings where guidelines also encourage GPs to view overweight when associated with a comorbidity as doctorable. 31 A recent Canadian study on patient perspectives on the role of primary care in overweight management, for example, highlighted how patients expect GPs to doctor their weight sensitively. 32 Like our study, they suggest that simplistic dietary and lifestyle advice will not work for everyone, 32 especially in the context of a long-term condition. They recommend GPs engage in the 5A framework for weight management (Ask-Ask-Assess-Advise-Agree-Assist) as it is associated with increased patient motivation to manage and lose weight. 33