Table 3 Detailed thematic analysis

Barriers to conversations

Lack of training

Lack of training in weight loss counselling was a significant recurrent barrier in literature

‘Primary care physicians often feel inadequately prepared to provide this counselling… brief weight loss counselling training for resident and primary care physicians may be necessary’ (Huang et al., 2004).

‘Although physicians acknowledge the importance of weight management, many report they lack training and confidence to provide counseling to enhance weight loss’ (Davis et al., 2008).

‘Health professionals repeatedly report a lack of confidence in knowing how to address obesity in their patients. They report minimal, if any, training on obesity as well as limited resources for effective conversations and insufficient clinical time to be able to do this well’ (Gordon & Black, 2016).

Insufficient time

Lack of time to provide weight loss advice, particularly when there are other issues to address

‘It is likely that GPs have little time during a single consultation to dedicate to lifestyle advice in one consultation’ (Booth & Nowson, 2010).

‘…many physicians report they lack adequate training and time to counsel patients about weight loss and are often fatalistic about the efficacy of obesity treatment’ (Davis et al., 2008).

‘Many providers feel they cannot devote clinical time to weight management when faced with acute and chronic demands to manage disease states and illnesses stemming from diabetes, heart disease, hypertension, and dyslipidemias’ (Greiner et al., 2008).

Poor resources

Insufficient reimbursement and insufficient resources available to perform weight loss counselling

‘Lack of physical and human resources to encourage and support weight loss was the main perceived barrier to helping patients achieve physical activity and weight loss goals’ (Eley & Eley, 2009).

‘Guidelines may not be specific or operational enough’ (Cox et al., 2011).

Multiple papers refer to lack of reimbursement as a barrier to weight loss discussions (Nawaz et al., 1999; Rose et al., 2013; Shiffman et al., 2009).

Pessimism

Pessimism in regards to patients’ willingness to take on advice/willingness to change/effectiveness of weight loss conversations in general

‘Physicians did not believe that patients would attempt and succeed at losing weight as a result of their counselling’ (Alexander et al., 2007).

‘…physicians tend to have a more negative outlook on patient weight and behaviors than patients do. For example, physicians were more likely than patients to think that patients lack self-control to stay on a diet. Physicians also tend to believe that patients have less motivation and think that patients will lose less weight than patients themselves believe’ (Post et al., 2011).

Complex topic

Associated with lack of training, physicians felt that the multifactorial nature of obesity makes it difficult to address

‘For diet the situation is even more complex. Sustained reductions in body weight will usually require a cut in energy intake, but responsible dietary management of obesity must also reduce the associated health risks … there is a diverse collection of messages about the overall composition and nutritional balance of the diet, which can be difficult for consumers to assimilate’ (Jebb et al., 2003).

‘…physicians may feel reluctant to address the topic of obesity in the first place, with the fear of offending patients or confirming feelings of failure at weight loss’ (Sherson et al., 2014).

More immediate needs

Associated to insufficient time, physicians noted that patients often had more acute medical issues to address

‘Many providers feel they cannot devote clinical time to weight management when faced with acute and chronic demands to manage disease states and illnesses stemming from diabetes, heart disease, hypertension, and dyslipidemias’ (Greiner et al., 2008).

Communication tools

5 A’s

Framework: Ask, Advise, Assess, Assist, Arrange

Framework for addressing change behaviour, initially developed for smoking cessation. Evidence for effectiveness in weight loss conversations.

‘The 5A’s is a framework developed for smoking cessation counseling in the office setting, and is also useful for most areas of preventive counseling in primary care’ (Jay et al., 2010b).

‘Using the 5A’s … as a weight counseling strategy has been associated with increased motivation to lose weight and increased weight loss’ (Gudzune et al., 2012).

‘The 5As counseling framework is an evidence-based way to teach physicians to counsel obese patients and measure the quality of obesity counseling. This framework guides providers to assess risk, current behavior, and readiness to change, advise change of specific behaviors, agree and collaboratively set goals, assist in addressing barriers and securing support, and arrange for follow-up (Jay et al., 2010a).

‘Physicians' use of the 5As is associated with higher odds of patient motivation to lose weight, intention to eat healthier, and intention to exercise’ (Jay et al., 2010b).

‘The 5 As, developed for smoking cessation, can be adapted for obesity counseling. The 5 As are appealing, as they are rooted in behaviour change theory and can be implemented in busy practice settings’ (Vallis et al., 2013).

Motivational interviewing (MI)

Principles for discussing change behaviour. Focus on patient’s thoughts and perspectives, with an aim to overcoming ambivalence and moving through the change cycle.

‘Motivational interviewing (MI) is one approach to patient-centered communication that addresses behavior change. MI may be used by health care providers to explore and resolve ambivalence regarding behavioral change. When physicians use MI when speaking with patients, they seek to elicit patients’ own reasons for change, act as partners, are supportive, explore their patients’ concerns, and convey that patients are the drivers of their own change process’ (Bravender et al., 2013).

‘…use of MI consistent techniques was associated with improvement in patient confidence to improve nutrition as well as a modest increase in patient reported exercise level’ (Cox et al., 2011).

‘The principles of MI, including providing empathy, collaborating with clients, and supporting client autonomy, are consistent with the elements of patient-centered care and consensus recommendations for working with clients from different cultures in obesity treatment’ (Carcone et al., 2013).

‘The technique of motivational interviewing (MI) can also effectively promote weight loss. Patients’ whose primary care providers employed MI consistent techniques during counseling demonstrated greater confidence to change their diet’ (Gudzune et al., 2012).

‘MI is patient-centered, not doctor-centered. This means that the physician listens to the patient’s perspective on how the problem affects daily life and seeks to understand the patient’s point of view without judging or criticising the behavior. The goal of MI is to elicit the patient’s motivation to change and to encourage the patient to take responsibility for his/her behavior’ (Schwartz, 2010).

4 E’s

Similar framework to 5A’s: engage, empathise educate, enlist

General communication technique, not specific for weight loss

The 4E model was chosen to teach anaesthetic trainees communication skills because ‘it is based on literature that reflects both primary care and procedural settings… it has been widely and successfully used in brief workshops with physicians…’ (Eggly et al., 2003)

Written materials

Potential to address inconsistencies in weight loss advice with written materials for patients to receive

‘Weight management activities in primary care are limited and inconsistent, with GPs reluctant to raise the subject of weight, and many lacking confidence in existing treatments. [Standardised written material] intervention addresses these issues, offering a simple, low-cost, treatment that can be delivered by primary care staff without special expertise’ (Beeken et al., 2012).

Language and communication

Empathetic

Expression of empathy is related to positive feedback from patients receiving weight loss advice

‘…participants indicated that they were more likely to have favourable weight-related interactions with physicians who possessed certain qualities, such as being empathetic, sensitive, respectful, trustworthy, compassionate, nonjudgmental, encouraging, honest, and comforting’ (Chugh et al., 2013).

‘…despite the overall paucity of expression of empathy, its presence was associated with improvement in Fat and Fiber scores as well as trends towards improvement in motivation scores and weight loss attempts’ (Cox et al., 2011).

Patient-centred (specific)

Advice to patients is more meaningful if personalised and not generalised weight loss advice

‘…participants expressed a desire for specific advice and personalised weight management plans… when women received generalised and nonspecific weight loss advice from their physician, they equated this with lack of concern, attention and support’ (Chugh et al., 2013).

;Providers should make dietary and physical activity advice in pregnancy more clear and individualised and offer such guidance multiple times throughout pregnancy’ (Ferrari et al., 2013).

‘Physicians may be able to improve care for their obese patients by focusing discussions on specific details of diet and physical activity behaviors, and by clarifying that patients perceive weight-related information has been shared’ (Greiner et al., 2008).

‘A clinician engaging in patient-centered, shared decision making may be most likely to tailor specific behavioral recommendations for patients to consider, adjust the amount of information conveyed, and arrange referrals to appropriate external resources’ (Greiner et al., 2008).

‘As with all health behavior change initiatives in health care, general statements from a physician may be less effective than stage assessment, specific advice or assistance, tailored counseling, and resource coordination’ (Greiner et al., 2008).

‘…the patient-centeredness of the physician was strongly associated with patient intentions… suggests that how counseling skills are delivered matters and that quality of the physician/patient relationship may influence the patients' commitment to behavior change’ (Jay et al., 2010b).

Specific terminology

Specific terminology to use

Specific terminology to avoid

Acknowledgement of patients excess weight

‘Many people thought “overweight” or “heavy” would be the most acceptable way for someone to describe their weight status… “Large”, “High BMI”, “Unhealthy weight” and “Excessive weight” were also endorsed as acceptable terms’ (Gray et al., 2011).

‘Reactions to the terms “obese”, “fat” and “excessive fat” were usually adverse’ (Gray et al., 2011).

‘“Unhealthy BMI”, “High BMI” and “Unhealthily High Body Weight” were often felt to be good terms to motivate weight loss: they were seen as professional and providing a clear definition of the problem’ (Gray et al., 2011).

‘Patients rated “weight” as the most desirable term for their physician to use to describe overweight or obesity, whereas “fatness” was the least desirable term rated by patients’ (Dutton et al., 2010).

‘…twice as many parents preferred the term gaining too much weight compared with the term overweight. Further, the authors reported that if parents perceived weight-related terms as hurtful or judgmental during healthcare communications, such perceptions negatively influenced even the most well-intentioned intervention’ (Farnesi et al., 2012).

‘The terms “fatness” and “obesity” have negative connotations and elicit negative reactions in patients; whereas “weight”, “overweight” and “Body Mass Index” were judged favourably, with “weight” being the most desirable term’ (Mikhailovich & Morrison, 2007).

‘…the terms “fat” and “fatness” are the least preferred terms. The words “obese” and “obesity” have also been found to arouse negative responses’ (Gordon & Black, 2016)

‘…patient reports of being told by a physician that they were overweight were associated with more realistic perceptions of the patients’ own weight, desire to lose weight, and recent attempts to lose weight’ (Post et al., 2011).

Specific recommendations

Training for physicians

Training for physicians may be of benefit in overcoming barriers to weight loss conversations

‘Non primary-care specialties may need to tailor current physician-patient communication models to their setting in order to train residents in interpersonal and communication skills’ (Eggly et al., 2003).

Ashby et. al. stated that education and confidence in knowledge had a positive impact on likelihood to provide weight loss advice, therefore targeted education programs to provide current information could provide positive behaviour change (Ashby et al., 2012).

Clear referral pathways

Clear referral pathways should be available for management of overweight/obesity

‘Office-based approaches to obesity management remain extremely challenging. Early recognition of overweight and obesity and communication to patients about the realities of their weight is an important initial step to successful behavior change. Implementing or referring patients for intensive weight loss interventions may be effective for some patients’ (Baron, 2011).

‘Formalisation of referral pathways and follow up is currently lacking and could assist rural GPs in helping their patients to exercise and lose weight’ (Eley & Eley, 2009).

‘Patients should be assisted in identifying and seeking out credible weight-management resources and be referred to appropriate providers for management (i.e. emphasizing an interdisciplinary approach). Arranging follow-up is important so that the support of the physician recommendations can continue’ (Vallis et al., 2013).

Specific consultation suggestions

Some specific consultation suggestions regarding perioperative overweight/obesity conversations:

- Acknowledgement of overweight/obesity initially

- Use of checklists for practitioners

- Patients to complete short form regarding diet and exercise prior to consultation

- Discussion of increased risks of obesity in perioperative period

- Limit amount of information conveyed so as to not overwhelm patient

- Brief interventions have significant impact on smoking cessation, potential for similar impact in weight loss

‘Health care providers should acknowledge their patient’s excess body weight as a first step in counselling patients…’ (Ahn et al., 2012)

‘Use of chart stickers and checklist forms to remind practitioner—also patients can complete short form regarding diet and exercise while waiting’ (Ahn et al., 2012).

Suggestion for candid discussion of increased risks in the perioperative period with obese patients including the suggestion that surgery is deferred to allow further time for weight loss (Astin & Hardy, 2015).

Anaesthetists can overload patients with more information than they can process in the pre-anaesthetic visit: ‘At baseline, an average individual can recall approximately seven “chunks” of new information. Against this backdrop, we observed an extreme tendency toward information overload by health care providers, coupled with a failure to use memory-enhancing techniques’ (Sandberg et al., 2008).

‘Even when doctors provide brief simple advice about quitting smoking this increases the likelihood that someone who smokes will successfully quit and remain a nonsmoker 12 months later’ (Stead et al., 2013).