What treatment options for intentional weight loss do patients with obesity complications prefer?

Preliminary indications from ongoing Irish research are that patient preferences could play a significant role in the adherence to obesity treatment and improved outcomes

Long-held as a self-inflicted condition, obesity has finally been recognised as a chronic disease, requiring lifelong intervention. In 2021, the European Commission issued a brief for policymakers, which stated that “obesity is a chronic relapsing disease that acts as a gateway for other diseases”. The other diseases in question include metabolic dysfunction-associated fatty liver disease (MAFLD), diabetes, cancer, kidney disease, and heart disease. In addition to the policy statement from the European Commission, the World Health Organisation issued a position statement in May 2017 clearly recognising obesity as a disease, with its own symptoms, signs, pathophysiology, and complications. This has led to an increasing awareness of the need to provide treatment. The number of people with the disease of obesity is increasing, but it remains difficult to predict what will happen in the future given that not all people are equally susceptible to develop the disease. The high numbers at present will result in a corresponding increase in obesity-related complications, and some authors have projected that diabetes will increase by 21 per cent, cancers by 61 per cent, and coronary heart disease and stroke by 97 per cent. The increase in potentially life-threatening complications will have a substantial negative impact on patients’ morbidity and mortality as well as adversely affecting their quality-of-life. This global epidemic will have a significant impact economically due to the associated increase in healthcare costs.

The components of evidence-based medicine include the best available evidence, clinical expertise, as well as taking a patient’s values and circumstances into consideration. These components are essential to provide an optimal treatment plan that is patient focussed. Moreover, patient values and circumstances impact their choice of available treatment options. Accommodating patient preferences, where feasible, has a positive influence on their engagement with their management plan. As such, patient preference is one of the foundations of patient-centred care and is informed by the patient’s beliefs, values, expectations and goals for their health. Understanding decision making and the importance of patients’ values and goals has become an essential part of the provision of quality care. Involving both healthcare providers and patients in establishing an obesity treatment plan has the potential to lead to improved adherence to treatment, and better health outcomes. Current obesity treatments include nutritional therapies, pharmacotherapies, and surgical therapies. Treatment options that produce >10 per cent weight loss can make a significant health improvement to those with obesity complications. However, patients with obesity complications are poorly informed about those treatment options for intentional weight loss.

Study details

Factors are now being identified that influence patient preferences and subsequent choice of obesity treatment among those seeking treatment for obesity-related complications. Participatory action research (PAR) facilitates the expansion of knowledge through collective investigation between researchers and participants, to gain an in-depth understanding of patient perspectives. In our study, patients were recruited from specialist clinics for MAFLD, diabetes, hypertension, and chronic kidney disease. Purposeful sampling was used to recruit 33 patients with obesity complications, who had a BMI >35kg/m². Reflective thematic analysis, an approach that analyses data about people’s perceptions, views, and experiences, was used. The interview questions were discussed by the research team and developed using both knowledge gained from previous research projects, as well as feedback from the Stratification of Obesity Phenotypes to Optimise Future Obesity Therapy (SOPHIA) project. The interviews began with broad questions about their complications and experiences, followed by specific questions surrounding treatment preferences. This identified the motivations and factors influencing patient decisions. The interviews ranged between 30-to-45 minutes, for an in-depth exploration of participants’ views.

Themes

Four main themes emerged: 1) structural factors of healthcare setting; 2) autonomy; 3) interaction with formal care; and 4) the emotional and physical consequences of obesity. Initial data from this study has identified factors within these themes that influence decisions around treatment options for the disease of obesity. These included access to healthcare, cost, lack of knowledge, and the perception that they are not being heard by healthcare professionals. In respect to the preferences for specific treatments, 39 per cent of participants preferred nutritional therapy with support from medical professionals. There was a preference that the healthcare professional should be an advanced nurse practitioner or a GP and not a dietician. Overall, 24 per cent of participants chose medication, 27 per cent chose surgery, while the remaining 9 per cent chose a combination or no intervention.

This research of the lived experiences of patients with obesity-related complications is ongoing, but the initial data is highlighting that patients feel they are not being heard by healthcare professionals and often found the interaction around weight demoralising, with limited follow-up care. Participants reported that if they perceived they were not being heard, they would simply shut down and not engage. For patients with the disease of obesity, this has a significant impact as they often experience shame and stigmatisation surrounding their disease, making them reluctant to seek help. Preliminary data indicates that the perspective of not being heard and limited knowledge about treatment options influenced participants’ choices and their engagement in the healthcare pathway. Patient-centred care enhances a patient’s autonomy, as it allows them to participate in discussions of the various treatment options, so that their values and needs can be taken into account as the healthcare professionals and patients reach a consensus on optimal, patient-specific obesity treatment, and follow-up management.

Another theme identified was a lack of knowledge on the part of healthcare professionals about the different treatment options for intentional weight loss. Participants reported that the lack of knowledge among healthcare professionals about obesity treatment options was a barrier to them. Several participants reported that they viewed their care as fragmented. A need to have consistent support was identified and their preference was for a meeting every few months with a healthcare professional, such as a nurse or GP, which they felt would enable them to better express all the complexities of their obesity-related complications management.

The emotional and physical consequences of obesity complications impacted participants’ treatment preferences. The increased mass of adipose tissue causes a spectrum of problems from obesity stigma to sleep apnoea to osteoarthritis to diabetes. The participants in this study reported that as their health deteriorated, they were more likely to engage with options that would resolve their medical issues quickly, especially if the deterioration affected treatment of concurrent disease(s). Many patients with obesity struggle with emotional issues of low self-esteem, quality-of-life, and poor body image, and this plays a negative role in seeking treatment. Indeed, when the topic of weight is discussed, words matter. Many patients felt judged, blamed, labelled negatively, and often self-stigmatised.

Health literacy is essential for patients who are managing obesity complications to ensure they can understand, evaluate, and use health information effectively. Improving health literacy for patients requires healthcare professionals to ask questions to evaluate what level of understanding the patient has, so they can add additional information if required. Providing training or education for patients on their condition and the value of self-care can also help increase confidence and support interactions with healthcare professionals. Part of the research study involved providing a video to participants where each treatment option was explained by experts in equipoise. The participants positively viewed the video. Implementing such an approach as part of patient care could be beneficial, as it would provide balanced information needed to make informed decisions about treatment.

Moving forward

Preliminary indications are that patient preferences could play a significant role in the adherence to obesity treatment and improved outcomes. Providing a structure that allows informed decision making between both the patient and their healthcare professional may help to establish the optimal approach for patients. The challenges emerging from the findings can be addressed by increasing support and education for healthcare professionals and improving the health literacy of patients. Improved communication, supportive consultations with healthcare professionals, and longer-term supports such as follow-up meetings with the healthcare professional are also required. We need to better understand access to treatment pathways for patients as well as how to develop health literacy programmes and educational programmes for healthcare professionals.

The treatment options for the disease of obesity are now better than ever, but we need to ensure that healthcare professionals have an in-depth understanding of treatment options, the availability of those options for their patients, as well as listening to the patient voice, to improve how we deliver better obesity care.

References on request

Hilary C Craig; 2 Zoë M Doran;3 and Prof Carel W Le Roux 1
1. Professor of Chemical Pathology, Diabetes Complications Research Centre, Conway Institute of Biomedical and Biomolecular Research, School of Medicine, University College Dublin (UCD). 2. PhD Researcher, Diabetes Complications Research Centre, Conway Institute of Biomedical and Biomolecular Research, School of Medicine, UCD. 3. Independent Researcher, Cork