The 5As team patient study: patient perspectives on the role of primary care in obesity management

Background Over 60% of people have overweight or obesity, but only a third report receiving counselling from primary care providers. We explored patients’ perspectives on the role of primary care in obesity management and their experience with existing resources, with a view to develop an improved understanding of this perspective, and more effective management strategies. Methods Qualitative study employing semi-structured interviews and thematic analysis, with a sample of 28 patients from a cohort of 255 patients living with obesity and receiving care to support their weight management in a large Primary Care Network of family practices in Alberta. Results Four illustrative themes emerged: (1) the patient-physician relationship plays an important role in the adequacy of obesity management; (2) patients have clear expectations of substantive conversations with their primary care team; (3) complex conditions affect weight and patients require assistance tailored to individual obesity drivers; (4) current services provide support in important ways (accessibility, availability, accountability, affordability, consistency of messaging), but are not yet meeting patient needs for individual plans, advanced education, and follow-up opportunities. Conclusions Patients have clear expectations that their primary care physician asks them about weight within a supportive therapeutic relationship. They see obesity as a complex phenomenon with multiple drivers. They want their healthcare providers to assess and address their root causes - not simplistic advice to “eat less, move more”. Patients felt that the current services were positive resources, but expressed needs for tailored weight management plans, and longer-term follow-up.

care settings, that for example include diet, exercise, and counselling or behavioural therapy, improve obesity prevention and management (referred to herein as weight management) [13,17,18]. Patients want their primary care providers to address their weight concerns [5].
The 5As Team program of research aims to address this gap. The program has partnered with a Primary Care Network (PCN) in Alberta, Canada, and worked with frontline interdisciplinary healthcare providers to help them improve their clinical practice [19][20][21][22]. As a component program, we wanted to explore patient needs and experience with PCN weight management resources to inform the results of the provider study, and to begin the process of designing an intervention. PCNs in Alberta have the mandate to enhance family practices with access to interdisciplinary teams to improve chronic illness prevention and care using a patient-centred approach [23]. To achieve patient-centeredness it is vital to understand patients' expectations and experiences of healthcare services. We conducted a study answering the questions 1) From the perspective of patients who seek primary care support for weight management, what role do clinicians play in their efforts? 2) How do PCN resources offer meaningful support and satisfy patients' needs? The purpose of this study is to lay the foundation for co-creation with patients of an intervention for a planned randomized control trial. This paper presents the results of this qualitative study. Unique is our focus on patients' perceptions of the role of primary care providers and PCN programming in overall weight management. This foundational research is needed to develop effective and sustainable interventions.

Methods
The 5As Team intervention study (5AsT) is a longitudinal randomized control trial with convergent mixedmethods evaluation that has been described in detail elsewhere [19]. The qualitative sub-study recruited 28 patients from the 5AsT longitudinal patient cohort. Patients were over 18 years old, had given written informed consent in English, and had a BMI > = 25 kg/m 2 . Purposeful sampling targeted individuals who received care of a PCN dietician or participated in a group program to support weight management at least 6 months prior. This ensured that patients were able to comment on the utility of PCN resources for their weight management. Over a 9-week period MB conducted qualitative interviews following a semi-structured interview guide (Appendix 1). The University of Alberta's (U of A) Health Research Ethics Board (HREB) provided institutional ethics approval (Pro00036740).
Interviews were transcribed verbatim, edited for clarity and confidentiality, and formatted for analysis. We used thematic analysis and iteratively coded data revising our list of codes continuously based on emergent patterns that were discussed regularly in analysis discussions with the research team [24,25]. To ensure validity we used analyst triangulation that included the development of a coding scheme between three investigators (JT, MB, DCS), as well as independent coding of each interview by two investigators (JT, MB). Codes were cross-checked and differences discussed to reach consensus. Emergent themes were critically discussed with the third author (TL) to maintain reflexivity and minimize bias [26]. To maintain confidentiality we used pre-established codes to replace formal names of interviewed patients, primary care providers, and family practice clinics.

Results
A total of 28 individual interviews were conducted with patients from a variety of ages, sexes, socioeconomic status and medical co-morbidities (Table 1). While interviews illustrate the individual character of patients' Coordinated and person-centred care Patients described their weight management efforts as inseparably tied to other physical, mental, and socioeconomic conditions. These conditions pose significant barriers to patients' weight management efforts causing feelings of frustration with their ability to reduce weight ( Patients explained how painful conditions, such as knee injuries, chronic pain, asthma, osteoarthritis, and plantar fasciitis, impaired their mobility and reduced the amount and level of their physical activity. Some patients reported weight gain from prescription medication, and other mechanical concerns such as sleep apnea. Patients also shared personal stories of their challenges and struggles with obesity and mental health. In these stories, patients link their weight, eating and weight control behaviours to stressful life events, depression, traumatic childhood experiences, fatigue, stress, and addictions. In addition, patients identified Type 2 diabetes, prediabetes, hypertension, and gout as associated with their weight. Women described struggling with the effects of menopause. These metabolic conditions often required restricted diets that patients found difficult to realize in their everyday lives. Finally, patients discussed limited finances and time constraints that affect their means to maintain or commit to an obesity management program. Patients are aware of the connection between their overall health, socio-economic well-being, and comorbidities with their overweight, and they look for support to assess, prioritize, and plan their weight management holistically.

The role of family physicians
Patients had clear and consistent expectations concerning the role of primary care in their weight management. They believed that it is the responsibility of the family physician to initiate the conversation about weight management, and to do so in a non-judgmental, knowledgeable and respectful manner. They felt that the conversation should be guided by a holistic view of weight that acknowledges the patients' overall health and well-being.
Patients discussed how aspects of their encounter with family physicians affect their satisfaction with weight management support (Table 3). These included perceived quality of relationship with the physician, the physician's approach to weight management and knowledge of obesity, and the time spent on the topic. Some patients reported a positive doctor-patient relationship with their family physician, were at ease discussing their weight, and believed their physician had listened and responded to their needs and concerns. A number of patients perceived their physician as effectively communicating weight management options. In addition, patients appreciated physicians who considered their overall health rather than addressing weight in isolation of other health concerns.
Other patients stated that their family physician never discussed weight. Some patients attributed this to a lack of time during the consultation. Others felt their family physician either ignored or did not recognize their weight concerns and the effect it is has on not only their health and wellbeing, but also their family, social, and work life. Some patients felt that their physician's failure to address weight was due to the patient's general good health. These patients, however, would have preferred their physicians' respond to their concerns and willingness to discuss weight management as a preventative measure. Several patients reported that their physicians expressed weight management was outside their field of expertise and referred them to a dietician or chronic disease management nurse. Some patients experienced their physician's approach to weight management as a variation of 'eat less and move more' , which they found unhelpful and ineffective.
Primary care network resources for weight management Patients described participation in the PCN educational sessions (Table 4) as useful and beneficial for weight management. Several patients had one-on-one support from dieticians in the PCN. Patients explained that these PCN resources facilitated their weight management through three key elements: accountability, accessibility, and consistency (Table 5).

Accountability
Patients expressed that their participation in the programs and the interactions with staff helped to hold them accountable when it came to weight management. They emphasized accountability as a major benefit of using PCN resources. For example, some patients stated regularly scheduled sessions alone increased their commitment. Other key benefits of these programs included explicit goal setting and deliberate follow-up with a PCN clinician to discuss successes and challenges that the Negative experience • "My family physician has never ever talked about my weight." (Patient 5) • "My family physician would give me the standard, 'Eat less fat, eat less sugar (chuckle), exercise more,'-and that's not going to cut it" (Patient 2) • "They were like, 'Okay, cut your calories and exercise,' and that was their only thing… Eat less and exercise more isn't the end-all-be-all. I'm looking for more concrete strategies." (Patient 11) patient experienced. Patients expressed that setting goals and working towards achieving them as best as they could, helped them to maintain their motivation.

Accessibility
A major strength of the PCN supports was their accessibility including availability of interdisciplinary clinicians, accommodating schedules, and affordable cost. Patients described benefitting from access to nutritionists, exercise specialists, and behavioural health consultants that focused on underlying psychological issues and behavioural change. In addition, they benefited from access to clinic nurses, which assisted with healthy weight loss and weight maintenance. However, patients also expressed that despite dietician availability, access is insufficient because of lengthy waiting times and lack of capacity to provide individualized support and follow-up. Weight management sessions were offered after work and on weekends, with PCN clinicians available to patients beyond regular scheduled sessions. In addition, an Alberta Health grant funds the PCNs, as such program fees are either gratis or nominal, which considerably lowers the financial barriers to participation. Having affordable access to these weight management resources, patients perceived the PCN as more "caring" and patient-centered as compared with commercial weight loss programs. Patients' experience of the PCN as caring played a significant role in their decision to access the PCN as a weight management resource.

Consistency
Another element of PCN resources and supports that emerged as significant for patient satisfaction was consistent weight management messaging. Patients remarked that a core point in this messaging was that weight loss is not a 'quick fix' and they should consider their weight management as a journey that will take commitment and time.

Patients' weight management needs
Four additional areas of weight management support were identified: (1) more individualized weight management resources; (2) addition of more advanced educational sessions; (3) enhanced advertisement; and, (4) further follow-up (see Table 6).

Strategies for individual sets of comorbidities
Patients had a good understanding of the multifactorial issues at play in their weight management and expressed the need for resources tailored to their particular situation. While patients appreciated that group programs provided a venue to share experiences with other patients, they found that the content remained too broad, thus not providing strategies that are applicable to their particular situation. They suggested that increasing the opportunity for one-on-one interaction would help them to address their individual weight management challenges.

Advanced weight management knowledge
Although patients understood the broad nature of the educational sessions and appreciated that they start at a very basic level, they felt that they would also benefit from more advanced educational resources.

Linking and advertising resources
Patients indicated the need for better promotion and advertisement of weight management resources and programs. Improved descriptions of programs would allow patients to make informed decisions about which resources would benefit their weight management best.

Follow-up
Patients expressed that extended follow-up with primary healthcare providers would improve their overall weight management experience, increase patient and provider accountability to meet their weight management goals, and help address any challenges patients may be experiencing. In addition, sometimes patients felt overwhelmed with the volume of information given in one consultation and would prefer long-term weight management resources. They felt ongoing access to resources and programming would be supportive in establishing new and improved eating behaviours, and encourage commitment to sustainable behaviour change.

Discussion
Family physicians should play a vital role in weight management, which is consistent with current literature [3,13,15,17,27,28]. Physicians should play a dual role in initiating weight management consultations with a • The other part would be accountability. That there is an opportunity either at the PCN or at the doctor, whoever wants to take the lead that can be an ongoing follow-up. I think the programs are great, but when the program ends, what happens next to that patient? . . . And, the thing is this is a lifestyle thing. So all of those things are great building blocks on your lifestyle, but what is going to keep you working on that lifestyle, to improve in general. So, it would be an ongoing connection, I think, with a PCN or with the doctor. I think PCN would be a great place to continue because they have some resources that the doctor's offices don't always have. (Patient 23) • I'd love something that could be ongoing! Almost like a course where it was a whole year long and you make a commitment to it…Yeah I'd love something like that where you're more accountable, there's more follow up, and you can ask questions and express your concerns. (Patient 2) comprehensive assessment and coordinating care of conditions and comorbidities that affect weight. In addition, we found that PCN services support weight management in important ways that meet patient needs for accessibility, accountability, and consistency. Finally, the results point to where patients' needs are not met and future efforts are warranted. Patients clearly articulated that they would like their family physician to initiate weight counselling, which is consistent with existing literature [3,5,16,29]. However, our findings emphasize the need to assess root causes and drivers of weight gain, comorbidities, and psychosocial barriers of individual patients in order to develop a care plan that offers realistic and sustainable strategies according to patients' particular constraints and strengths. Patients felt that their weight is a complex phenomenon impacted by a multitude of factors. Consistent with literature that categorizes common conditions associated with obesity into the "4Ms of obesity management" [6], patients discussed mechanical, mental, metabolic, monetary issues as inseparable from their weight trajectory and has having decisive impact on their weight management efforts. This resonates with the mounting evidence showing that obesity is a complex condition that is impacted by multiple factors beyond diet and exercise [3,5,16,30,31]. Consequently, weight management in primary care must build on an individual assessment of a person's history with weight, attempts at weight control, comorbidities, mental health, and socio-economic situation. Findings underscore that patients want personalized information about physiology of obesity, its chronicity and resistance to treatment in order to formulate personal strategies with realistic expectations, and a focus on prevention and patientimportant health outcomes rather than numbers on a scale. In addition, treatment plans must be guided by the recognition that behaviour and behaviour change arises at the intersection of cultural and social environments with individual factors such as automatic responses, conscious choice, values, and physiology [3,5,32,33]. Family physicians are ideally positioned to develop such personalized care plans based on their long-term relationship with patients and the lifecycle approach of primary care.
Our findings show that while patients expect physicians to initiate and coordinate weight management; extended interdisciplinary health teams contribute valuable care and resources beyond the constraints of physicians' time and expertise. This echoes previous research calling for multidisciplinary teams to address obesity [3,5,15,16].
Patients appreciated the sense of accountability to their weight management goals through PCN programming. The importance of accountability for behaviour change has been found previously and points to the relational quality of human behaviour [2,32]. Goal setting and follow-up, in concert with social support, facilitates the establishment of healthy habits [34,35]. Patients value consistent messaging around prioritizing health improvement instead of focusing on weight alone, realistic expectations for weight loss, and the holistic understanding of obesity. Such consistency in conceptualizing and framing weight management for patients supports their sense-making of their condition and their ability to manage it [21]. These findings support the potential of the Patient Medical Home model, that the PCN structure is based on for improving weight management and obesity care [23,36].
Beyond these benefits of current weight management resources, patients emphasized the lack of personalized care plans including information that applies to patients' particular combination of challenges and offers knowledge that is appropriate for diverse levels of education. They also emphasized the need for long-term, sustainable approaches and for better coordination of existing resources in the community. Challenges to address these needs include a lack of physician education in obesity physiology and training in weight management skills resource constraints for patient-centeredness of the current health care model and the lack of an evidence-based, yet flexible and adaptable, intervention [3,13,17,29,30].
Practice implications of our findings include a clear need for personalized weight management interventions that are practical and sustainable for interdisciplinary primary care clinicians. The "5As for obesity management™" (Ask-Assess-Advise-Agree-Assist) offer a promising framework that can guide practitioners in addressing patients' individual weight management needs in a way that is patient-centred, comprehensive, and coordinated [13,15,21,22,27,37]. The 5As are gaining traction in the US and Canada [13,15,19,27,[37][38][39][40], have been shown to improve provider self-efficacy, increase weight management visits [13], and result in clinically significant patient weight loss at 12 months post-intervention with a physician trained in the 5As [24]. However, considering the chronicity and complexity of obesity as well as research questioning the utility of weight loss as measure for successful management [41], there is a pressing need for further research identifying appropriate patient outcome measures.
Furthermore, research is needed to understand how a comprehensive, personalized assessment and weight management plan can be implemented in diverse health care settings, in particular where extended interdisciplinary teams are not available and budget is limited, and how to build capacity in other interdisciplinary team members to support patient weight management.
There are some limitations of this study. All patients in this cohort had a family physician and received PCN weight management care. While 85% of Canadians have a family physician, and over 80% of Albertans belong to a PCN, the services and structures vary across different geographic regions. Although we achieved diversity of patients for gender, age, and stages of obesity, the majority of the group identified as Euro-Canadian and as urban/suburban residing in a major city in Alberta. The themes that emerged from the data reflect the perspectives of patients who are concerned about their weight and willing to work with clinicians to improve their health. While our conclusions are not generalizable to all patients living with obesity, they are foundational to developing an intervention that is effective for patients who seek support for their weight management within primary care.

Conclusion
These results further our understanding of patients' perception of if, when, and how primary care clinicians and resources can support weight management. The study is part of the larger 5AsT research program to improve weight management in primary care. Moving beyond patient experiences of living with and managing excess weight, this research examined how patients perceive the weight management support provided by extended interdisciplinary teams embedded in family medicine practices, such as the PCN model in Alberta, Canada.
Overall, patients expressed the need for weight management that is tailored to their individual set of comorbidities and provides strategies that are realistic and sustainable under their personal circumstances.