Waikato GP perspectives on obesity management in general practice: a short report

Keywords: general practice, health care, inequity, obesity, opinion, perspective, primary care, weight management.

Obesity is a significant health issue worldwide, with New Zealand (NZ) ranked the third most obese nation in the Organisation for Economic Co-operation and Development (OECD).^1,2 Obesity prevalence in NZ adults is 34.3%, with indigenous Māori population at 50.8% and Pacific at 71.3%.³ Obesity is a complex health concern, with a myriad of contributing factors, many of which are outside the bounds of general practice.^4–7 However, obesity is reversible and preventable through a combination of dietary, exercise, and behavioural changes actioned in culturally appropriate ways.⁸ The Ministry of Health (MOH) positions primary care and general practice as best-suited to deliver weight management due to their frequent contact with patients and their ability to ‘monitor, assess, manage and maintain’ their patients weight and obesity risk.⁸

Obesity rates are reportedly rising in recent decades,⁹ suggesting that potentially the current weight management model is ineffective. Given the known equity gap, finding effective approaches for reducing obesity for Māori and Pacific people should be a priority. Previous literature has highlighted that GPs experience difficulties in the ‘delicate’ discussion of weight, often utilising opportunistic strategies in their practice.¹⁰ Barriers experienced included a lack of effective interventions, limited resource availability and obesity stigma.¹¹ Bariatric surgery has mixed reviews, with some GPs expressing the positive life-changing effects it has on some patients through weight loss and reduction of obesity comorbidities. However, other GPs consider this a drastic option that fails to deal with the root cause of the patient’s obesity.¹¹

The current NZ model generally allocates GPs 15 min for a patient consult. Improved pathways to effective weight management are needed to help general practice deal with the obesity epidemic and its associated health impact on their patients, given the limited time and resources they have at their disposal. The aim of this study was to explore GP perspectives of four areas to obesity management in Waikato general practice to help focus on areas for improving the care of adults with weight problems.

This study utilised a cross-sectional design. A questionnaire consisting of four multi-choice questions, each with a free-text comment box, for participants to elaborate on why they chose their answers, was provided.

Participants were recruited in one of two ways. First, a short article and electronic link to participate in a Survey Monkey questionnaire was published in the Waikato District Health Board (WDHB) June 2021 newsletter. This was emailed to 494 GPs across the Waikato region and 17 participant responses were collected. Second, paper copies of the same questionnaire were handed out to all (n = 18) GP attendees of a monthly Waikato GP meeting in Hamilton in July 2021, with 12 responses collected. No demographic data were collected.

The questionnaire consisted of four questions addressing GPs’ perspective on: deciding to raise weight in a consultation; preferred option to treating obesity; their perspective on whether obesity management is a general practice issue; and their use of bariatric surgery. Due to obesity being such a complex and multi-levelled issue,¹ a comments box was included for all questions so participants could elaborate on their experiences for qualitative analysis. This questionnaire was designed in collaboration with the Waikato DHB GP Liaison team. Descriptive statistics were used to analyse the quantitative data,¹² and content analysis¹³ was used for the qualitative comments. Ethical approval was granted by the University of Waikato Human Research Ethics Committee reference (HREC2020#38).

Table 1 details the Survey Questionnaire multiple choice results. Table 2 offers a selection of participant free text comment quotes, which, combined with the other quotes detailed in the sections below, form the findings of this study.

Table 1.  Participant responses to the survey questions.

Table 2.  Selection of participant free-text comments box quotes.

The majority of GPs (69%) reported that weight discussion was case dependant and would speak about weight if their patient asked (Table 1). Discussion of weight was reported as a ‘very tricky topic to introduce’ (Participant 16) as there was a high ‘risk of causing offense’ (Participant 07), which was positioned as something to avoid in their role as a GP. A lack of time available in the consultation, the quality of the GP–patient relationship, and how relevant weight was to the presenting health issue were all noted as factors in their decision.

Although the majority (82.8%) of GPs indicated they would offer weight management themselves (Table 1), many commented that this was case dependant and ‘depends on what patient wants’ (Participant 25) or the patients' ‘needs, finances, [and] motivation’ (Participant 06). Many participants highlighted that offering weight management advice was the first option ‘of many’ used and that referring patients was preferable for obesity management. Nine GPs positioned nurses as a common referral option as they have ‘more time and more resources to offer the patient’ (Participant 12).

The majority (62.1%) of GPs did not believe tackling the obesity epidemic was their responsibility (Table 1). Obesity was positioned as a ‘multifactorial problem with multifaceted management’ (Participant 18) needs. Although weight management was noted to have a place in general practice, it requires ‘all healthcare professionals’ (Participant 26) and is a ‘shared’ (Participant 29) responsibility. It is ‘a combined effort strategy’ (Participant 14) with patients, general practice, ‘fast food control labelling’ (Participant 29), ‘primary health care and public health’ (Participant 09) and national policy all having a responsibility.

Most GPs (75.9%) reported referring a participant for bariatric surgery in the last 2 years (Table 1). Perspectives of the effectiveness of this intervention strategy varied. There was a significant theme of ‘caution’ towards the long-term success of the surgery by some participants and that it is ‘good, but needs lifelong commitment’ (Participant 22). With ‘limited availability via public funding’ (Participant 15), the surgery was commonly positioned as ‘largely an option for the wealthy’ (Participant 14), whereby those who could fund the surgery personally or afford health insurance received the surgery.

This study contributes new information to the GP perspectives of obesity health care situated in general practice, and thus warrants further exploration. The majority of GPs reported they would wait for their patient to raise the issue of their weight, would offer weight advice themselves as a first option before considering referral, did not view general practice as best suited in tackling the obesity epidemic, and utilised bariatric surgery as a referral option while noting the inequities in access.

Difficulties in discussing weight, options for referral and treatment were identified barriers to effective weight management in general practice, which supports similar studies in NZ.^10,11 Psychological and sociocultural factors have been recognised as contributing aspects to obesity development,^14–17 yet surprisingly, there was a lack of comments on how addressing these might facilitate discussion, referral or treatment options. One GP (Participant 14) specifically indicated that depression and anxiety would be a barrier to raising the issue of weight with a patient, whereas physiological health concerns such as blood pressure or joint pain were more likely to trigger a discussion. Culturally appropriate health care is crucial for positive health changes, specifically with Māori and Pacific patients; however, this was not highlighted as a utilised referral option by the study participants.¹⁸ Referrals to counsellors, psychologists or Māori/Pacific health-care providers are effective obesity treatment options that were not recognised or were overlooked in this survey.

Bariatric surgery was found to be primarily an option for ‘wealthy’ patients, indicating an additional layer to the inequity in access to this effective treatment. Recent literature has highlighted that in one area of NZ, Māori and Pacific populations are less likely to receive bariatric surgery compared with other ethnic groups, despite experiencing higher obesity.¹⁹ Although there have been recent discussions about best practice moving forward regarding Māori nutrition,^20,21 and identification of ethnic disparities across the board for publicly funded surgery,^19,22 there is evidence that obesity is a major health concern for all New Zealanders^1,3,23 and that solutions are urgently needed. Those living in socioeconomically deprived areas reportedly are 1.6-fold more likely to be obese in NZ,³ and yet there are financial barriers in accessing this treatment, suggesting an equity issue that needs to be addressed.

This study had a small sample size with no demographic data collected from participants. Although the findings cannot be generalised, the aim was to briefly explore GPs views and identify if more research is warranted in this context. The complex nature of obesity health care was stressed by these GPs. Many barriers are experienced in general practice and from the participants’ perspectives, effective treatment options are limited. Overall, this exploratory study found more guidance seems to be needed in how and when to raise the issue of obesity with patients, and there is a need for a wider and more diverse availability of referral options, a better understanding of the resources needed to achieve effective weight loss and an examination of the inequities apparent in the access to bariatric surgery.

Due to the low number of participants from a small geographical region of NZ, the data that supports this study cannot be publicly shared due to ethical and privacy reasons. The data may, however, be shared upon reasonable request to the corresponding author if appropriate.

The authors declare that they have no conflicts of interest.

This project was part of a larger PhD project for Kimberley Norman (University of Waikato), which is funded by the Waikato District Health Board Research Trust.