Nutritional care: the importance of knowing how to address the subject beyond having nutritional knowledge
Excess weight and obesity can contribute to the development of chronic diseases, and healthcare professionals have a key role in their prevention. General practitioners interact a lot with overweight and obese patients and are led to provide nutritional counselling. A cross-sectional survey studied the patient-general practitioner interaction according to the patient’s body weight. It has been shown that a patient’s excess weight has an influence on the interaction with the general practitioner, as they both have different beliefs about what causes excess weight and obesity.
While the World Health Organization (WHO) estimates that the worldwide prevalence of obesity almost tripled between 1975 and 2016 (WHO, 2021), general practitioners have a key role in medical care (Schwenke M. et al, 2020), especially to reduce and prevent excess weight and obesity that can lead to the development of chronic pathologies (Budreviciute A. et al, 2020). To successfully help these patients, they require skills in several areas, such as prevention, education, counselling or assisting in the care pathway (Durrer D. et al, 2019).
Previous studies highlighted the necessity of communication, motivational interviewing and therapeutic patient education during consultations. New guidelines mention the importance of avoiding stigmatization, and of considering managing the psychological aspects of excess weight and obesity, such as improving self-esteem, body image and quality of life (Forgione N. et al, 2018). This cross-sectional study (Gimenez L. et al, 2023) aims to analyse whether the interaction between patients and their general practitioner, as measured by their disagreement on elements given during the consultation, varied according to the patients’ body mass index (BMI).
A greater disagreement between the patient and the physician when the patient is overweight or obese
General practitioners deliver information and are led to discuss different topics about the patient’s health during medical consultations. This study shows that the more overweight the patients were, the greater they would disagree with information and advice given by the physician on weight, physical activity, and nutrition. The agreement between the patient and the practitioner, especially on health problems, is associated with positive health outcomes and compliance, and is a variable described as practical, useful, and a relevant indicator of the adequacy and effectiveness of information sharing among patients and doctors in other studies (Liaw S. et al., 1996 ; Coran J. et al., 2013).
Results of the study show that the proportions of overweight and obese patients (14,5% and 24,3% respectively) in disagreement with their general practitioners on information about weight were at least 10 times higher than the proportion of patients with a BMI<25 kg/m2 (1,4%) in disagreement on this topic. When talking about advice given by the physician related to weight loss, the proportions of overweight and obese patients (18,2% and 19,4% respectively) in disagreement were 9 times higher than the proportion of patients with a BMI<25 kg/m2 (2,1%) in disagreement.
In fact, the higher the degree of the patient’s excess weight was, the greater the disagreement between patients and general practitioners was, especially on questions related to weight. Comprehension difficulties can be responsible of the disagreement between the patient and the practitioner, especially due their different modes of representation regarding excess weight and obesity.
Overweight and obese patients’ perception of the causes and consequences of excess weight
Overweight and obese patients have their perceptions of what causes excess weight and obesity, and their consequences. In fact, the study shows that, among the 137 patients who considered themselves overweight or obese, 37,3% estimated that excess weight was due to a biological origin, 29,9% attributed them to a social origin, and 23,9% to an individual and behavioural origin. These results show that even if social and behavioural determinants are increasingly identified to explain overweight in literature (WHO, 2000 ; Basdevant, 2006), biological origin is still perceived as the main reason by some patients (Foster G. et al., 2003).
In terms of social consequences of excess weight and obesity, 66,4% of the concerned patients declared that there were no consequences of their excess weight on any aspect of their lives. However, 21,6% of them thought it had consequences on their personal and family lives, 12,7% on their social lives and 4,5% on their professional lives. Regarding the health consequences, the more overweight the patients were, the more they considered that their weight had consequences on their health or represented a risk for the future.
These results show that patients tend to attribute their excess weight or obesity first to causes independent of their control, especially biological causes. A divergence in the representation modes of excess weight exists between patients and practitioners, which suggests difficulties of comprehension and relationship.
Which dialogue to address overweight or obese patients?
This study shows the importance of the manner of speaking while addressing patients about nutrition, especially overweight and obese patients. Indeed, overweight and obese patients are often victims of discrimination and stigmatization (Kinzl JF et al, 2016), which can cause bad health conditions and make their medical follow-up difficult (Tomiyama AJ. Et al, 2018). Lifestyle changes could improve their health, especially regarding cardiovascular risk associated with overweight and obesity.
To promote a lifestyle change, the European guidelines for adult obesity management in primary care are in favour of a patient-centred approach, including psychological aspects of obesity and the prevention of weight regain. They highlight that the multifactorial origin of obesity should encourage a multidisciplinary support, coordinated by general practitioners (Durrer D. et al, 2019).
Moreover, such findings show that nutritional knowledge might not be enough when physicians face overweight and obese patients. These elements are an opportunity for general practitioners to rethink their communication during consultations, especially regarding lifestyle and weight-related advice. Physicians can propose an exploration of the patient’s beliefs and difficulties related to overweight and obesity to establish a discussion with appropriate support. To help general practitioners improving their relationship with their patients, the study suggests training in communication skills, therapeutic education, or motivational interviewing.
Based on: Gimenez L. et al. Interaction between patient and general practitioner according to the patient body weight: a cross-sectional survey, Family Practice, 2023, 40, 218-225.
- Data of the study were collected from the quantitative phase of the INTERMEDE protocol, using “mirrored” questionnaires collecting both general practitioner and patients’ perceptions on information and advice given at the end of the consultation.
- 27 volunteered general practitioners were recruited in France and 585 patients were recruited, making 585 patient-general practitioner pairs. Patients fitted the following criteria: between 18-80 years old, no first-time patient, no pregnant women nor women who have given birth in the last 6 months, no emergency visit, and consenting to participate in the whole study.
- The patient’s body mass index (BMI) used follow the who categories (normal = 18.5-24.9 kg/m2, overweight = 25-29.9 kg/m2 and obese > 30 kg/m2) and the “weight difference” is the difference between the patient’s BMI category and general practitioner’s BMI category.
- “Mirrored” questions have been asked to assess the disagreement between the patient and the general practitioner. The discordant pairs (i.e. “general practitioner = yes, patient = no” or “general practitioner = no, patient = yes”) for a number of questions were identified and used to define “disagreement”.
- Patients and general practitioners sometimes disagree during a consultation, especially when talking about lifestyle and weight loss.
- Overweight patients are more likely to disagree regarding these topics.
- These disagreements could degrade the patient-general practitioner relationship and impact the efficacity of medical care for weight loss.