Role of general practitioners in the care and treatment of obesity

In principle, all respondents considered the GP to be the right contact person to advise patients in matters of prevention of overweight and related risk factors, and the one to take therapeutic measures if necessary. Many respondents emphasised that the GP is in the best position to “pick up patients at their own situation” (I-2 m) and to support them in their overweight management on the basis of an established relationship of trust in the long term.

“I believe that the general practitioner is the best possible authority to turn to, for only he/she knows me well enough and is aware of the problems I have. He/she is who I trust most.” (I-10f).

In the opinion of most respondents (24), the advice and assistance given by their GPs was of greater importance than the recommendations of other physicians or health professionals when it came to achieving weight loss and promoting a healthy lifestyle.

Experiences with general practitioners

In the course of the interviews, we identified several problem areas of GP care provision of people with obesity (see Fig. 1).

Fig. 1

Identified problem areas of obesity care provided by general practitioners

30 of the 32 respondents stated that they had already discussed their weight with their current or a previous GP. In some cases, check-up examinations were mentioned as occasions for weight counselling, participation in a disease management programme or a treatment of diabetes were also mentioned in individual cases. The majority, however, stated that there had been no specific reason and that weight had been discussed rather casually (see Fig. 1, point 1).

“The fact that we came to talk about my overweight was more or less coincidental. It was not actively controlled now.“ (I-18f).

18 respondents stated that the doctor originally had taken the initiative and brought up the subject of obesity; whereas 12 other persons had consulted the GP.

“I have been consulting my general practitioner for a long time, but he has never approached me openly about the subject. […] We just stumbled upon it at some point.“ (I-22f).

According to statements made by 12 persons, weight counselling took place once, for 6 persons more often than once, and 12 respondents stated that overweight issues had become a recurring topic of conversation since it had been brought up the first time. However, a majority (20) admitted that conversations about the weight situation had taken place earlier or very irregularly and that it often had not been foreseeable for them when the topic would come up again (see Fig. 1, point 2).

Issues of weight counselling

In almost all cases (28), the GPs emphasised the negative consequences of obesity. After the overweight had been identified, some of the physicians (14) were also concerned to find out possible causes so that individual needs could be better addressed.

“No, he didn’t ask more specifics on that. He then very quickly moved on to the recommendation.“ (I-18f).

Based on the agreement between physician and patient that weight reduction should be aimed for, a majority (22) described that a moderate reduction in weight was recommended with the goal of maintaining the new weight. However, only 6 individuals reported that specific goals were agreed upon. Most often. the time frame in which progress should be made also remained an open question (see Fig. 1, point 3).

Twenty-four respondents stated that general dietary counselling had been provided. The physicians frequently had recommended a low-calorie diet and given specific advice such as avoiding certain foods or substituting certain products (“lots of vegetables, little meat”). Other patients had been advised to reduce the amount of food they ate and change their eating rhythm (“regular eating habits”), or even their ‘eating culture’ (“conscious eating”). In individual cases (6), the GP would hand out a diet plan. In two cases, an app specifically for dietary change had been recommended. Beyond the actual consultation and isolated measures such as diet plans, the physicians rather rarely recommended additional help and support services. 6 persons mentioned referrals to dietary counselling, health insurance offers, self-help groups, special cooking courses or spa stays.

While nutrition was addressed comparatively often, only a smaller number of respondents recalled exercise counselling. Beyond general references to the importance of regular exercise, 10 respondents described suggestions for physical activities (e.g., getting an exercise bike, joining a cardiac sports group, swimming, walking). Hardly any concrete suggestions were made concerning the frequency and intensity of physical activities. 4 persons stated that the GP had referred them to concrete offers of help (e.g., health fitness centres, courses offered by community colleges).

Satisfaction with general practitioner care

Most respondents (18) positively rated that the GP had principally signalled their willingness to help, had pointed out the risk factors of being too overweight and had responded to queries. In addition, a partnership-like relationship was praised (16).

“The trust level is just very high, yes. So the preconditions are already fulfilled.“ (I-6 m).

However, many respondents criticised the care which their GPs actually provided. In particular, they strongly expressed that no continuous guidance had taken place; often one or two relatively short conversations on the subject of overweight was all they had (see Fig. 1, point 2).

“It was kind of like this: ‘Once and then never again.‘ It just didn’t amount to much that way. There was nothing like continuous care worth mentioning.“ (I-14 m).

Another widespread point of criticism, also voiced by those respondents for whom the GP had suggested specific measures for weight reduction, had to do with the absence of success criteria. Since there had been no goals to be achieved beyond general recommendations, they had lacked an orientation benchmark and a motivating element (see Fig. 1, point 3).

“It would have helped me a lot if I had known when to achieve what. I mean goals that are set specifically for you.“ (I-24 m).

“In what time should I achieve what and how? These questions have not been clarified exactly. And if you lack that, then you don’t have a compass when you lose weight. […] Then the whole thing is quickly doomed to failure.“ (I-28f).

According to their own statements, ten respondents had been successful in reducing their weight noticeably and sustainably in recent years or months. This is attributed to the support of the GP by 4 persons. A huge number of the respondents (18) refer to what they see as a lack of therapeutic support. Apart from general counselling, there had been a “lack of a coherent, clear concept [of] how the pounds should fall off” (I-2 m).

“You can’t call it therapy. Just a ‘you should do this and could do that’” (I-30m).

In addition, from the point of view of a majority of the respondents (20), the GPs made too few complementary offers in the process of care as to what help and support options were available for continuous weight loss and an increase in fitness in the local vicinity (see Fig. 1, point 4).

“No, there was far too little coming. It seemed to me that he didn’t know much about such courses either, like what kind of possibilities existed.“ (I-18f).

“I felt a bit fobbed off. ‘Take some kind of course’. Which one? What? Where is there something here?“ (I-30 m).

Ten respondents mentioned that they felt that there had occasionally been a lack of empathy on the part of GPs when dealing with the weight situation (see Fig. 1, point 5). Situations were described in which rude, arrogant or insulting behaviour on the part of the physicians became apparent. In two cases, this stigmatising behaviour resulted in the termination of the physician-patient relationship.

“I felt that he was cracking little jokes on me, saying something like: everything will soon collapse under you should you go on like this.“ (I-20f).

In addition, a widespread passivity of physicians has been described (14), which had led to patients feeling left alone with their weight problem. This is partly associated with negative attitudes of practitioners towards people with obesity (6).

“Patients like us have experienced this before […]: Physicians who do not give us much credit. The fat ones can’t get it together, they just can’t stop eating.“ (I-14 m).

Care needs

Regardless of the care actually experienced, the majority of the respondents favoured a proactive approach by GPs when dealing with overweight patients. An open but polite and sensitive approach was advocated.

Central to almost all interviewees are continuous discussions that serve to provide ongoing advice and, not least, motivation. The intervals should ideally be a few weeks in order, for example, to be able to analyse reasons for failure in good time and to try out new approaches.

“If there are no such deadlines, then you quickly lose sight of it and let things slide. You have to keep at it regularly to overcome your weaker self.“ (I-10f).

The respondents attached great importance to agreeing on tangible goals (weight to be reduced, time periods) and measures. In doing so, action steps should be chosen to accommodate patients’ sensitivities and interests.

“I would like to enrol in a structured diet or exercise programme, teaching me how to lose weight slowly but surely. And also goals that I can measure myself against.“ (I- 28f).

Respondents articulated a desire for referrals or referrals to help, whether it be health insurance options, fitness classes, or support groups. The GP is seen as a good platform from which to raise awareness of such flanking offers.

“If my GP recommended such a course to me, I would definitely be much more likely to accept it than if I had heard about it somewhere else.“ (I-30 m).