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Doctors and patients’ perspectives on obesity. A Q-methodology study

Doctors and patients’ perspectives on obesity. A Q-methodology study Background: Obesity is associated with stigma and discrimination. Health care providers should approach these patients professionally and without stigma, since treatment of obesity requires a relationship with mutual understanding between the doctor and patient. Objective: To explore how patients and general practitioners (GPs) perceive obesity, using Q-methodology, which allows quantitative analysis of qualitative data. Methods: A Q-methodology study, comprising 24 patients with obesity and 24 GPs. We created 48 statements with viewpoints on obesity. All participants sorted these statements in a forced grid with a quasi-normal distribution ranking from −5 (most disagree) to +5 (most agree). Subsequently, factor analysis was performed. Six patients were interviewed to explain their viewpoints. Results: Analysis yielded 3 dominant groups (factors) of patients: (i) They acknowledge the importance of healthy lifestyle and feel mistreated by health care. (ii) They have a decreased quality of life, but do not blame health care, and (iii) They don’t need treatment and don’t have an impaired quality of life. For the GPs, the 3 dominant factors were: (i) They have understanding for the patients and feel that health care is insufficient, (ii) They believe that obesity may be hereditary but mainly is a lifestyle problem, and (iii) They believe obesity can be treated but is very difficult. Conclusions: Viewpoints on obesity were different, both within and between the groups. Some GPs consider obesity mainly as a lifestyle problem, rather than a chronic disease. If patients and doctors can find mutual viewpoints on obesity, both patient satisfaction and a treatment strategy will be more effective. Lay Summary Obesity affects quality of life and increases the risk of diseases such as type 2 diabetes, fatty liver disease, cardiovascular disease, and cancer. Achieving and maintaining weight loss is difficult and for this reason a mutual understanding between the general practitioner (GP) and the patient is crucial. We used Q-methodology to study the patients and GPs perspectives on obesity. We show that there are different groups of patients that have different perspectives on obesity, but also different groups of doctors who have different perspectives on obesity. If the GP is aware of the fact that the patients’ viewpoints regarding obesity may be different than his/her own viewpoints, it allows improvement of the doctor–patient communication and hence, patient satisfaction. Key words: factor analysis (statistical), health communication, obesity, patient satisfaction, primary health care, qualitative research Introduction a result of weight stigma and discrimination, and may lead to social isolation. Current treatments for obesity comprise The misconception that obesity is a lifestyle choice, that can lifestyle changes including diet and exercise, drugs, psycho- be reversed simply by exercising willpower, has become ce- therapy, and bariatric surgery. mented in the minds of the general public and much of the The general practitioner (GP) is often the first doctor who medical profession. However, obesity has now been acknow- meets the patient with obesity-related problems. However, as ledged by the European Commission as a disease in its own 1 mentioned above, many GPs do not consider obesity as a ser- right. The obesity pandemic is getting worse in both adults 2 ious medical condition that requires treatment, but rather as and children and adolescents. In Sweden, 15% of women 3 a lifestyle problem. This discrepancy has a negative impact on and 16% of men suffer from obesity. It is a complex chronic 4 the relationship between doctors and patients. In addition, metabolic disease with a multifactorial pathogenesis, asso- there is scepticism regarding the treatment options for obesity, ciated with type 2 diabetes mellitus, nonalcoholic fatty liver 5 but GPs still recommended them in order to maintain a good disease, cardiovascular diseases, and different types of cancer. relationship with the patient. Previous research demonstrates In addition, obesity has consequences for mental health as © The Author(s) 2022. Published by Oxford University Press. This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial License (https://creativecommons.org/ licenses/by-nc/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited. For commercial re-use, please contact journals.permissions@oup.com Downloaded from https://academic.oup.com/fampra/advance-article/doi/10.1093/fampra/cmab169/6505219 by DeepDyve user on 18 January 2022 2 Doctors and patients’ perspectives on obesity Key messages • Viewpoints on obesity differ, both within and between patients and GPs. • Different subgroups of viewpoints on obesity can be identified with Q-methodology. • Some GPs consider obesity a lifestyle problem, rather than a chronic disease. • Q-method is suitable for investigating subjective experiences and perspectives. the importance of good communication between GPs and pa- Methods tients to increase the probability that an intervention will be- Setting and data sources come successful. We searched for opinions and viewpoints on obesity in dif- One method to study people’s perspectives on a certain ferent articles and in forums. This led to 52 statements. An topic is via Q-methodology, which is a combined qualitative expert group from the Obesity Unit (consisting of a doctor, a 11,12 and quantitative method for investigating subjectivity. nurse, a dietician, a psychologist, and a physiotherapist) evalu- This method is well-established in the social sciences, but re- ated these statements and selected a Q-set comprising 48 state- mains a relatively novel approach in the medical sciences. It ments. We transferred the Q-set to www.qmethodsoftware. provides a systematic procedure for examining the subjective com, and evaluated the statements to confirm that the lan - components of human behaviour, where all the viewpoints guage was understandable and that the Q-set could be distrib- of the subjects are clustered into different groups, called uted within the forced-choice grid without conflicts. factors. Twenty-four doctors, all GPs or GP residents (16 men and 8 Firstly, the researcher gathers all kinds of opinions, beliefs, women), and 24 patients with obesity (21 women and 3 men) and information about a topic from different sources, such were included. The number of participants is based on the con- as previous research and interviews and creates statements vention that 1 needs roughly half as many participants as there about the topic. This is followed by an evaluation of the state- are statements. Patients with obesity were recruited face to face ments, performed by a group of experts within the topic, to in- via the obesity unit of the University hospital in Örebro. The crease the value and content, but also to minimize researcher participating GPs were recruited during a local primary health bias. This evaluation leads to the creation of a so-called Q-set; care conference. The inclusion criteria for the patients were: (i) the final set of statements that will be used. Secondly, the body mass index >30 kg/m and (ii) that they had not started study population is selected, and the viewpoints of the par- with a weight-loss program provided by the Obesity Unit, since ticipants should match the research question. Subsequently, we did not want them to be influenced by the information that the participants rank the statements from their individual per- they would receive during this program. All participants were spective using a grid with a quasi-normal, forced distribution informed about the purpose and procedure of the study and (see Fig. 1). The grid has the same number of cells as there signed an informed consent. There was no dropping-out. For are statements and has a rating scale from −5 to +5 which the patients, the Q-methodology data were collected at the represents “most disagree” to “most agree.” All statements Obesity Unit, Örebro University Hospital. For the GPs, the must be placed in the grid. In addition, qualitative informa- Q-methodology data were collected at their workplace. No tion can be collected by interviewing participants about their other individuals were present during the data collection. One most extreme rankings. When the ranking is completed, all member of the research team (KB, female, medical doctor) also responses are reduced to a few different factors. Each factor consecutively interviewed 6 patients to obtain qualitative infor- represents a distinct group of participants who share similar mation about their most extreme rankings, and field notes were views. The number of extracted factors is usually between 3 made. No standard questionnaire was used for the interviews. and 6. Thereafter, a factor rotation is performed to make the The transcripts were not returned to the patients but were veri- factors more explainable. Each factor provides information fied directly on the spot. Each interview took approximately that defines that factor. 30  min. There was no earlier relationship between the parti- The aim of our study was to analyse both the patients and cipants and the research group. The research group was not the GPs perceptions about obesity using Q-methodology, and biased in any way with respect to viewpoints regarding obesity. to compare them with each other. -5 -4 -3 -2 -1 0+1+2+3+4+5 (2) (2) (3) (3) (4)(4) (5)(5) (6)(6) (8) MOST DISAGREE MOST AGREE Fig. 1. Score grid for Q-sorting. Downloaded from https://academic.oup.com/fampra/advance-article/doi/10.1093/fampra/cmab169/6505219 by DeepDyve user on 18 January 2022 Family Practice, 2022, Vol. XX, No. XX 3 Data analysis their distinguishing statements, as shown in Tables 1 and 2. Correlations between Z-scores for each statement between all Two members from the research team (QS and KB) imported factors are presented in Table 3. the anonymized results in PQMethod software. The first step Table 4 shows the statements where the different patients in the analysis was data reduction to summarize factors based and GP factors agreed and disagreed on most. The extracted on principal component analysis (PCA). The factors were ex- factors from the patients explained 62% of the variance of tracted from both the patient and the GP group. We calculated the original Q-sorts and the extracted 3 factors from the GPs the Z-scores, based on the factor scores from the PCA for every also explained 62% of the variance. In factor analysis, this is statement, which represented how much each factor agreed or considered as a valid and acceptable proportion of variance disagreed on every statement. A Pearson’s correlation ana- explained by a construct. lysis was performed (SPSS Statistics version 25, IBM Corp, Armonk, NY) to compare the 2 groups, using the Z-scores Factor 1 (patients): have knowledge about healthy from every statement from the patient and GP factors. food- and exercise habits and feel mistreated by health care providers Results Nine patients showed knowledge about lifestyle changes that We extracted 3 different factors from each group. Each lead to weight loss but they do not have good experiences factor represented a general viewpoint and was named after with these lifestyle changes. In contrast to the other patients’ Table 1. Distinguishing statements for the patient factors and their rank scores. Factor Statement Factor 1 Factor 2 Factor 3 Patient factor 1 41. Health care providers treat patients with obesity worse than those without 5 −1 1 7. Individuals with obesity have knowledge about healthy food 2 −1 0 9. Individuals with obesity understand the importance of eating healthy 2 0 0 43. Individuals with obesity have an impaired quality of life 1 4 −2 17. Regular meals protect against obesity 0 1 2 19. At least 30 min physical activity per day protects against weight gain 0 2 2 1. Obesity can be prevented 0 2 5 15. By reducing energy-rich food, weight loss will occur −1 1 2 8. Individuals with obesity have healthy food habits −1 −5 1 13. Obesity is more common among people with higher education and income −2 −3 −5 48. Individuals with obesity who increase their physical activity lose weight −2 3 1 Patient factor 2 43. Individuals with obesity have an impaired quality of life 1 4 −2 28. Early childhood is the time when food- and exercise habits are established 0 3 0 30. If you have parents who have obesity, you will develop obesity yourself −1 1 −2 47. Individuals with obesity receive enough support from healthcare −4 0 −3 44. Use of certain drugs leads to obesity 2 0 4 36. Individuals with obesity have knowledge about the risks with obesity 3 0 3 40. Doctors have too little knowledge about obesity 3 −1 2 41. Health care providers treat patients with obesity worse than those without 5 −1 1 24. Alcohol consumption does not increase the risk of weight gain −1 −2 0 46. Weight loss does not provide increased quality of life 0 −4 1 8. Individuals with obesity have healthy food habits −1 −5 1 Patient factor 3 21. Physical activity improves health regardless of weight 3 2 5 5. Obesity is not hereditary −2 −2 3 18. Obesity is often used as an excuse for not exercising −3 −1 1 8. Individuals with obesity have healthy food habits −1 −5 1 41. Health care providers treat patients with obesity worse than those without 5 −1 1 3. Obesity is a person’s own choice −5 −4 0 34. Individuals with obesity need treatment 2 3 −1 37. Individuals with obesity are not interested in their weight −4 −3 −1 39. Abuse in childhood increases the risk of obesity 1 1 −1 43. Individuals with obesity have an impaired quality of life 1 4 −2 45. Obesity is an eating disorder 1 0 −3 38. Individuals with obesity often feel bad mentally 4 4 −4 33. Obesity is a lifelong disease 1 1 −4 Bold value shows the rank score of significant statements for the specified patient factor. Downloaded from https://academic.oup.com/fampra/advance-article/doi/10.1093/fampra/cmab169/6505219 by DeepDyve user on 18 January 2022 4 Doctors and patients’ perspectives on obesity Table 2. Distinguishing statements for the GP factors and their rank scores. Factor Statement Factor 1 Factor 2 Factor 3 GP factor 1 41. Health care providers treats patients with obesity worse than those without weight problem 3 −3 −2 9. Individuals with obesity understand the importance of eating healthy 2 0 0 40. Doctors have too little knowledge about obesity 1 −1 −1 35. There is no effective treatment for obesity 0 −2 −4 48. Individuals with obesity who increase their exercise will lose weight −2 3 0 37. Individuals with obesity are not interested of their weight −4 −1 −2 3. Obesity is a person’s own choice −4 0 0 GP factor 2 45. Obesity is an eating disorder −1 4 −2 48. Individuals with obesity who increase their exercise will lose weight −2 3 0 23. Smoking increases the risk of weight gain −1 1 −3 25. The public judges individuals with obesity 4 1 4 13. Obesity is more common among people with higher education and income −5 0 −5 26. To lose weight is easy −5 −2 −4 7. Individuals with obesity have knowledge about healthy food 0 −2 2 24. Alcohol consumption does not increase the risk of weight gain −2 −4 −2 5. Obesity is not hereditary −2 −5 −3 GP factor 3 11. It is enough to change food habits to lose weight −1 −3 2 46. Weight loss does not provide increased quality of life −3 −4 0 48. Individuals with obesity who increase their exercise will lose weight −2 3 0 17. Regular meals protect against obesity 2 3 0 33. Obesity is a lifelong disease 1 2 −1 6. Individuals with obesity have an unhealthy lifestyle −2 −1 −4 32. 5–10% weight loss is not enough to live longer −3 −1 −5 Bold value shows the rank score of significant statements for the specified patient factor. Table 3. Correlations between Z-scores for each statement between all factors according to Pearson’s correlation analysis (P values). Patient factor 1 Patient factor 2 Patient factor 3 GP factor 1 0.808 0.773 0.568 GP factor 2 0.421 0.770 0.262 GP factor 3 0.471 0.792 0.509 The table shows that the correlations between the factors varied. Patient factor 1 had the highest correlation (r = 0.808, P = <0.001) with GP factor 1. However, it has a weak correlation with other GP factors. Patient factor 2 correlated well with all GP factors, meanwhile, patient factor 3 had a moderate correlation with 2 GP factors and the lowest correlation with GP factor 2. “I have had problems with my weight and hypothyroid- viewpoints, these patients strongly feel that health care is mis- ism since birth and even though I am told to eat right treating them. and despite doing so, you are criticized that you do not. One patient said: Throughout my whole childhood, I have eaten according to the plate model but I am still not properly treated.” I received documentation about a gastric bypass when I sought care for a urinary tract infection. They only think This patient explained that she felt criticized by her envir- that I have to train more, eat a low-calorie diet or should onment and although she felt that she was not treated ad- have a gastric bypass. You do not get help or support for equately, she understood how difficult it is to treat obesity. anything else. Factor 2 (patients): suffering from obesity for a long Factor 3 (patients): do not think that obesity has an time but do not blame health care providers impact on the quality of life and do not think they need any help Seven patients with obesity highlighted that early childhood is the time when food- and exercise habits are developed and Five patients believed that obesity does not affect the quality that there is a hereditary component. These patients confirm of life and that it is not a hereditary condition. Although they that obesity affects their quality of life. They believe that doc- are aware of their condition, they do not think they need tors have sufficient knowledge about obesity and that they treatment, and in contrast to other viewpoints, they do not receive support from health care providers. One patient said: think that obesity is a lifelong disease. One patient said: Downloaded from https://academic.oup.com/fampra/advance-article/doi/10.1093/fampra/cmab169/6505219 by DeepDyve user on 18 January 2022 Family Practice, 2022, Vol. XX, No. XX 5 Table 4. Statements where the different patients and GP factors agreed and disagreed on most. Group and factor number Significantly loaded statements Z-Score Patients factor 1 25. The public judges individuals with obesity 1.617 41. Health care providers treat patients with obesity worse than those without 1.516 27. To keep the weight stable after weight loss is difficult 1.384 2. Individuals with obesity are lazy −1.830 3. Obesity is a person’s own choice −1.941 42. Individuals with obesity do not want to lose weight −2.061 Patients factor 2 27. To keep the weight stable after weight loss is difficult 1.900 25. The public judges individuals with obesity 1.573 14. Obesity is a disease with several different causes 1.474 10. Snacks eating do not lead to obesity −1.435 8. Individuals with obesity have healthy food habits −1.462 26. To lose weight is easy −1.960 Patients factor 3 21. Physical activity improves health regardless of weight 1.857 1. Obesity can be prevented 1.569 44. Use of certain drugs leads to obesity 1.445 33. Obesity is a lifelong disease −1.522 13. Obesity is more common among people with higher education and income −1.584 26. To lose weight is easy −1.778 GPs factor 1 21. Physical activity improves health, regardless of weight 2.019 27. To keep the weight stable after weight loss is difficult 1.637 44. Use of certain drugs leads to obesity 1.360 42. Individuals with obesity do not want to lose weight −1.529 26. To lose weight is easy −1.627 13. Obesity is more common among people with higher education and income −1.807 GPs factor 2 21. Physical activity improves health, regardless of weight 2.079 14. Obesity is a disease with several different causes 2.052 28. Early childhood is the time where food- and exercise habits are developed 1.323 24. Alcohol consumption does not increase the risk of weight gain −1.688 5. Obesity is not hereditary −1.914 22. Stress does not increase the risk of weight gain −2.001 GPs factor 3 21. Physical activity improves health, regardless of weight 1.996 27. To keep the weight stable after weight loss is difficult 1.860 25. The public judges individuals with obesity 1.594 26. To lose weight is easy −1.742 32. 5–10% weight loss is not enough to live longer −1.849 13. Obesity is more common among people with higher education and income −2.014 The table shows the similarities and differences between the patient factors and GP factors. Among the patients, many personal statements were ranked highly. Among the GPs, medical facts about obesity were ranked highly. The majority disagreed with statement 26 and the majority agreed with statement 27. All GP factors and 1 patient factor agreed the most with statement 21, meanwhile 2 patient factors and 1 GP factor ranked statement 25 very highly. I think obesity depends on many things, both medications Factor 2 (GP): believe that obesity is hereditary and but also life situation. I think that if you look backward an eating disorder and look when you became obese, you can relate it to Four doctors believed that obesity is an eating disorder, as something that happened during that time. well as a hereditary condition. They agreed the least with the statement that people with obesity are negatively judged and disagreed the least with the statement that losing weight is easy. Factor 1 (GP): understand the patients and believe that health care provides insufficient support Factor 3 (GPs): obesity is not a lifelong disease but Ten doctors believed they have insufficient knowledge about it is difficult to lose weight obesity and that health care providers treat the patients with obesity worse than those without obesity. There is a certain Seven doctors believed that patients with obesity have a understanding for these patients. Distinguishing for this view- healthy lifestyle and that it is sufficient to change food habits point is that they are not sure whether there is an effective to lose weight. However, they do not have an opinion re- treatment for obesity. garding whether weight loss increases the quality of life or Downloaded from https://academic.oup.com/fampra/advance-article/doi/10.1093/fampra/cmab169/6505219 by DeepDyve user on 18 January 2022 6 Doctors and patients’ perspectives on obesity whether exercise leads to weight loss. Distinguishing from the almost all other viewpoints did, except GP factor 3. Patient other viewpoints, they believe that obesity is not a lifelong factor 3 had the lowest correlation with all GP viewpoints, disease. especially with GP factor 2, who strongly agreed on obesity as an eating disorder and strongly agreed on obesity as a heredi- tary condition. Obviously, this group do not consider obesity Discussion as a chronic metabolic disease. Several studies have shown the importance of good com- Strengths and limitations munication between GPs and patients. In our study we We used a method that is well established in the social sciences, focussed on the different perspectives on obesity both but remains a relatively novel approach in medical sciences. within and between GPs and patients. Our findings show The major strength of this method is that Q-methodology al- some differences and similarities in ranking between the lows statistical interpretation of qualitative data and provides distinguishing statements for the patients and GPs, leading a powerful method to investigate differences and similarities to 6 different factors on obesity. Three factors from patients in viewpoints between doctors and patients regarding their and 3 factors from GPs were considered important in this condition. study. There are some limitations. Selection bias may have been introduced. The GPs who participated may have been more Comparison to existing literature interested in obesity and were motivated to make a change, Patient factor 1 underlined their belief of the importance of compared with the GPs that did not choose to participate. combining diet and exercise for an effective weight loss Secondly, the participating patients may have had more nega- even though other studies suggest that also behavioural tive experiences with health care providers and they may strategies such as self-monitoring are required for a suc- experience a more impaired health and participated for this cessful result. Besides that, this group agreed strongly on reason. the statement that health care providers treat patients with obesity worse than those without obesity, which the other Conclusions groups did not. This patient factor had a high correlation with GP factor 1. The correlation between patient factor 1 We showed that viewpoints on obesity are different, both and the other GP factors was much lower, which may be within and between patients and GPs. A patient may have explained by the fact that these GPs did not highlight state- completely different viewpoints regarding his/her condition ments that were associated with discrimination and lack of than the GP. Some GPs show viewpoints that are not sup- knowledge about obesity. Instead, they highlighted medical ported by the current knowledge, such as considering obesity facts about obesity, which these patients did not take into mainly as a lifestyle problem, rather than a chronic disease. consideration. In addition, our findings show that a considerable number of In patient factor 2, this group seemed to have struggled patients feel stigmatized because of their obesity, and experi- with obesity for a long time and they were unsure whether ence impaired quality of life. For these reasons, awareness of health care providers could do more for them. This patient these differences is relevant for clinical practice; if the GP and group believed that patients with obesity have unhealthy the patient are able to find mutual viewpoints about obesity, eating habits, and they were neutral about their knowledge patient satisfaction will improve and a treatment and/or sup- regarding obesity-associated health risks. They confirmed port strategy will be more effective. that doctors have adequate knowledge about obesity, and did not feel that they were treated any differently than patients Funding without obesity. This is in line with studies in which patients with obesity reported positive experiences with health care. The study was funded by departmental resources. They also confirmed that obesity has an impact on quality of life, thus confirming previous research regarding the re - Acknowledgements lationship between obesity and a decreased quality of life. This viewpoint had a similar correlation with all the GP view- We thank the professionals at the Obesity Unit at the Örebro points, which means that they share similar opinions about University Hospital for their support with the review of the these statements. Q-sort statements. Patient factor 3 differed from the other patient factors and showed a believe that patients with obesity neither need treat- Ethical approval ment, nor have an impaired quality of life. This shows that there are patients with obesity who are less affected by their Ethical approval was granted by the Etikprövningsmyndigheten condition. These patients strongly disagreed on the statement Uppsala (Dnr 2019-04756). that patients with obesity suffer from impaired mental health, although previous studies demonstrate that obesity and de- Conflict of interest 19,20 pression often coexist and are interrelated. They also dis- agreed on the statement that obesity is a hereditary condition, None declared. and they were neutral about obesity as being a persons’ own choice, as well as that they agreed on that patients with obesity Data availability have healthy food habits. These patients neither seemed to feel bad about having obesity, nor did they want any help The data underlying this article will be shared on reasonable and nor did they consider obesity as a lifelong disease, which request to the corresponding author. Downloaded from https://academic.oup.com/fampra/advance-article/doi/10.1093/fampra/cmab169/6505219 by DeepDyve user on 18 January 2022 Family Practice, 2022, Vol. XX, No. XX 7 11. Akhtar-Danesh N. Qfactor: a command for Q-methodology anal- References ysis. Stata J. 2018;18(2):432–446. 1. Burki T. European Commission classifies obesity as a chronic dis - 12. Zabala A, Pascual U. Bootstrapping Q methodology to im- ease [published online ahead of print, 2021 Jun 1]. 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Overweight, obesity, and depression: a system- J, Qureshi S, Walter F, Whitehead MA. General practitioners’ and atic review and meta-analysis of longitudinal studies. Arch Gen patients’ models of obesity: whose problem is it? Patient Educ Psychiatry. 2010;67(3):220–229. Couns. 2001;44(3):227–233. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Family Practice Oxford University Press

Doctors and patients’ perspectives on obesity. A Q-methodology study

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Abstract

Background: Obesity is associated with stigma and discrimination. Health care providers should approach these patients professionally and without stigma, since treatment of obesity requires a relationship with mutual understanding between the doctor and patient. Objective: To explore how patients and general practitioners (GPs) perceive obesity, using Q-methodology, which allows quantitative analysis of qualitative data. Methods: A Q-methodology study, comprising 24 patients with obesity and 24 GPs. We created 48 statements with viewpoints on obesity. All participants sorted these statements in a forced grid with a quasi-normal distribution ranking from −5 (most disagree) to +5 (most agree). Subsequently, factor analysis was performed. Six patients were interviewed to explain their viewpoints. Results: Analysis yielded 3 dominant groups (factors) of patients: (i) They acknowledge the importance of healthy lifestyle and feel mistreated by health care. (ii) They have a decreased quality of life, but do not blame health care, and (iii) They don’t need treatment and don’t have an impaired quality of life. For the GPs, the 3 dominant factors were: (i) They have understanding for the patients and feel that health care is insufficient, (ii) They believe that obesity may be hereditary but mainly is a lifestyle problem, and (iii) They believe obesity can be treated but is very difficult. Conclusions: Viewpoints on obesity were different, both within and between the groups. Some GPs consider obesity mainly as a lifestyle problem, rather than a chronic disease. If patients and doctors can find mutual viewpoints on obesity, both patient satisfaction and a treatment strategy will be more effective. Lay Summary Obesity affects quality of life and increases the risk of diseases such as type 2 diabetes, fatty liver disease, cardiovascular disease, and cancer. Achieving and maintaining weight loss is difficult and for this reason a mutual understanding between the general practitioner (GP) and the patient is crucial. We used Q-methodology to study the patients and GPs perspectives on obesity. We show that there are different groups of patients that have different perspectives on obesity, but also different groups of doctors who have different perspectives on obesity. If the GP is aware of the fact that the patients’ viewpoints regarding obesity may be different than his/her own viewpoints, it allows improvement of the doctor–patient communication and hence, patient satisfaction. Key words: factor analysis (statistical), health communication, obesity, patient satisfaction, primary health care, qualitative research Introduction a result of weight stigma and discrimination, and may lead to social isolation. Current treatments for obesity comprise The misconception that obesity is a lifestyle choice, that can lifestyle changes including diet and exercise, drugs, psycho- be reversed simply by exercising willpower, has become ce- therapy, and bariatric surgery. mented in the minds of the general public and much of the The general practitioner (GP) is often the first doctor who medical profession. However, obesity has now been acknow- meets the patient with obesity-related problems. However, as ledged by the European Commission as a disease in its own 1 mentioned above, many GPs do not consider obesity as a ser- right. The obesity pandemic is getting worse in both adults 2 ious medical condition that requires treatment, but rather as and children and adolescents. In Sweden, 15% of women 3 a lifestyle problem. This discrepancy has a negative impact on and 16% of men suffer from obesity. It is a complex chronic 4 the relationship between doctors and patients. In addition, metabolic disease with a multifactorial pathogenesis, asso- there is scepticism regarding the treatment options for obesity, ciated with type 2 diabetes mellitus, nonalcoholic fatty liver 5 but GPs still recommended them in order to maintain a good disease, cardiovascular diseases, and different types of cancer. relationship with the patient. Previous research demonstrates In addition, obesity has consequences for mental health as © The Author(s) 2022. Published by Oxford University Press. This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial License (https://creativecommons.org/ licenses/by-nc/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited. For commercial re-use, please contact journals.permissions@oup.com Downloaded from https://academic.oup.com/fampra/advance-article/doi/10.1093/fampra/cmab169/6505219 by DeepDyve user on 18 January 2022 2 Doctors and patients’ perspectives on obesity Key messages • Viewpoints on obesity differ, both within and between patients and GPs. • Different subgroups of viewpoints on obesity can be identified with Q-methodology. • Some GPs consider obesity a lifestyle problem, rather than a chronic disease. • Q-method is suitable for investigating subjective experiences and perspectives. the importance of good communication between GPs and pa- Methods tients to increase the probability that an intervention will be- Setting and data sources come successful. We searched for opinions and viewpoints on obesity in dif- One method to study people’s perspectives on a certain ferent articles and in forums. This led to 52 statements. An topic is via Q-methodology, which is a combined qualitative expert group from the Obesity Unit (consisting of a doctor, a 11,12 and quantitative method for investigating subjectivity. nurse, a dietician, a psychologist, and a physiotherapist) evalu- This method is well-established in the social sciences, but re- ated these statements and selected a Q-set comprising 48 state- mains a relatively novel approach in the medical sciences. It ments. We transferred the Q-set to www.qmethodsoftware. provides a systematic procedure for examining the subjective com, and evaluated the statements to confirm that the lan - components of human behaviour, where all the viewpoints guage was understandable and that the Q-set could be distrib- of the subjects are clustered into different groups, called uted within the forced-choice grid without conflicts. factors. Twenty-four doctors, all GPs or GP residents (16 men and 8 Firstly, the researcher gathers all kinds of opinions, beliefs, women), and 24 patients with obesity (21 women and 3 men) and information about a topic from different sources, such were included. The number of participants is based on the con- as previous research and interviews and creates statements vention that 1 needs roughly half as many participants as there about the topic. This is followed by an evaluation of the state- are statements. Patients with obesity were recruited face to face ments, performed by a group of experts within the topic, to in- via the obesity unit of the University hospital in Örebro. The crease the value and content, but also to minimize researcher participating GPs were recruited during a local primary health bias. This evaluation leads to the creation of a so-called Q-set; care conference. The inclusion criteria for the patients were: (i) the final set of statements that will be used. Secondly, the body mass index >30 kg/m and (ii) that they had not started study population is selected, and the viewpoints of the par- with a weight-loss program provided by the Obesity Unit, since ticipants should match the research question. Subsequently, we did not want them to be influenced by the information that the participants rank the statements from their individual per- they would receive during this program. All participants were spective using a grid with a quasi-normal, forced distribution informed about the purpose and procedure of the study and (see Fig. 1). The grid has the same number of cells as there signed an informed consent. There was no dropping-out. For are statements and has a rating scale from −5 to +5 which the patients, the Q-methodology data were collected at the represents “most disagree” to “most agree.” All statements Obesity Unit, Örebro University Hospital. For the GPs, the must be placed in the grid. In addition, qualitative informa- Q-methodology data were collected at their workplace. No tion can be collected by interviewing participants about their other individuals were present during the data collection. One most extreme rankings. When the ranking is completed, all member of the research team (KB, female, medical doctor) also responses are reduced to a few different factors. Each factor consecutively interviewed 6 patients to obtain qualitative infor- represents a distinct group of participants who share similar mation about their most extreme rankings, and field notes were views. The number of extracted factors is usually between 3 made. No standard questionnaire was used for the interviews. and 6. Thereafter, a factor rotation is performed to make the The transcripts were not returned to the patients but were veri- factors more explainable. Each factor provides information fied directly on the spot. Each interview took approximately that defines that factor. 30  min. There was no earlier relationship between the parti- The aim of our study was to analyse both the patients and cipants and the research group. The research group was not the GPs perceptions about obesity using Q-methodology, and biased in any way with respect to viewpoints regarding obesity. to compare them with each other. -5 -4 -3 -2 -1 0+1+2+3+4+5 (2) (2) (3) (3) (4)(4) (5)(5) (6)(6) (8) MOST DISAGREE MOST AGREE Fig. 1. Score grid for Q-sorting. Downloaded from https://academic.oup.com/fampra/advance-article/doi/10.1093/fampra/cmab169/6505219 by DeepDyve user on 18 January 2022 Family Practice, 2022, Vol. XX, No. XX 3 Data analysis their distinguishing statements, as shown in Tables 1 and 2. Correlations between Z-scores for each statement between all Two members from the research team (QS and KB) imported factors are presented in Table 3. the anonymized results in PQMethod software. The first step Table 4 shows the statements where the different patients in the analysis was data reduction to summarize factors based and GP factors agreed and disagreed on most. The extracted on principal component analysis (PCA). The factors were ex- factors from the patients explained 62% of the variance of tracted from both the patient and the GP group. We calculated the original Q-sorts and the extracted 3 factors from the GPs the Z-scores, based on the factor scores from the PCA for every also explained 62% of the variance. In factor analysis, this is statement, which represented how much each factor agreed or considered as a valid and acceptable proportion of variance disagreed on every statement. A Pearson’s correlation ana- explained by a construct. lysis was performed (SPSS Statistics version 25, IBM Corp, Armonk, NY) to compare the 2 groups, using the Z-scores Factor 1 (patients): have knowledge about healthy from every statement from the patient and GP factors. food- and exercise habits and feel mistreated by health care providers Results Nine patients showed knowledge about lifestyle changes that We extracted 3 different factors from each group. Each lead to weight loss but they do not have good experiences factor represented a general viewpoint and was named after with these lifestyle changes. In contrast to the other patients’ Table 1. Distinguishing statements for the patient factors and their rank scores. Factor Statement Factor 1 Factor 2 Factor 3 Patient factor 1 41. Health care providers treat patients with obesity worse than those without 5 −1 1 7. Individuals with obesity have knowledge about healthy food 2 −1 0 9. Individuals with obesity understand the importance of eating healthy 2 0 0 43. Individuals with obesity have an impaired quality of life 1 4 −2 17. Regular meals protect against obesity 0 1 2 19. At least 30 min physical activity per day protects against weight gain 0 2 2 1. Obesity can be prevented 0 2 5 15. By reducing energy-rich food, weight loss will occur −1 1 2 8. Individuals with obesity have healthy food habits −1 −5 1 13. Obesity is more common among people with higher education and income −2 −3 −5 48. Individuals with obesity who increase their physical activity lose weight −2 3 1 Patient factor 2 43. Individuals with obesity have an impaired quality of life 1 4 −2 28. Early childhood is the time when food- and exercise habits are established 0 3 0 30. If you have parents who have obesity, you will develop obesity yourself −1 1 −2 47. Individuals with obesity receive enough support from healthcare −4 0 −3 44. Use of certain drugs leads to obesity 2 0 4 36. Individuals with obesity have knowledge about the risks with obesity 3 0 3 40. Doctors have too little knowledge about obesity 3 −1 2 41. Health care providers treat patients with obesity worse than those without 5 −1 1 24. Alcohol consumption does not increase the risk of weight gain −1 −2 0 46. Weight loss does not provide increased quality of life 0 −4 1 8. Individuals with obesity have healthy food habits −1 −5 1 Patient factor 3 21. Physical activity improves health regardless of weight 3 2 5 5. Obesity is not hereditary −2 −2 3 18. Obesity is often used as an excuse for not exercising −3 −1 1 8. Individuals with obesity have healthy food habits −1 −5 1 41. Health care providers treat patients with obesity worse than those without 5 −1 1 3. Obesity is a person’s own choice −5 −4 0 34. Individuals with obesity need treatment 2 3 −1 37. Individuals with obesity are not interested in their weight −4 −3 −1 39. Abuse in childhood increases the risk of obesity 1 1 −1 43. Individuals with obesity have an impaired quality of life 1 4 −2 45. Obesity is an eating disorder 1 0 −3 38. Individuals with obesity often feel bad mentally 4 4 −4 33. Obesity is a lifelong disease 1 1 −4 Bold value shows the rank score of significant statements for the specified patient factor. Downloaded from https://academic.oup.com/fampra/advance-article/doi/10.1093/fampra/cmab169/6505219 by DeepDyve user on 18 January 2022 4 Doctors and patients’ perspectives on obesity Table 2. Distinguishing statements for the GP factors and their rank scores. Factor Statement Factor 1 Factor 2 Factor 3 GP factor 1 41. Health care providers treats patients with obesity worse than those without weight problem 3 −3 −2 9. Individuals with obesity understand the importance of eating healthy 2 0 0 40. Doctors have too little knowledge about obesity 1 −1 −1 35. There is no effective treatment for obesity 0 −2 −4 48. Individuals with obesity who increase their exercise will lose weight −2 3 0 37. Individuals with obesity are not interested of their weight −4 −1 −2 3. Obesity is a person’s own choice −4 0 0 GP factor 2 45. Obesity is an eating disorder −1 4 −2 48. Individuals with obesity who increase their exercise will lose weight −2 3 0 23. Smoking increases the risk of weight gain −1 1 −3 25. The public judges individuals with obesity 4 1 4 13. Obesity is more common among people with higher education and income −5 0 −5 26. To lose weight is easy −5 −2 −4 7. Individuals with obesity have knowledge about healthy food 0 −2 2 24. Alcohol consumption does not increase the risk of weight gain −2 −4 −2 5. Obesity is not hereditary −2 −5 −3 GP factor 3 11. It is enough to change food habits to lose weight −1 −3 2 46. Weight loss does not provide increased quality of life −3 −4 0 48. Individuals with obesity who increase their exercise will lose weight −2 3 0 17. Regular meals protect against obesity 2 3 0 33. Obesity is a lifelong disease 1 2 −1 6. Individuals with obesity have an unhealthy lifestyle −2 −1 −4 32. 5–10% weight loss is not enough to live longer −3 −1 −5 Bold value shows the rank score of significant statements for the specified patient factor. Table 3. Correlations between Z-scores for each statement between all factors according to Pearson’s correlation analysis (P values). Patient factor 1 Patient factor 2 Patient factor 3 GP factor 1 0.808 0.773 0.568 GP factor 2 0.421 0.770 0.262 GP factor 3 0.471 0.792 0.509 The table shows that the correlations between the factors varied. Patient factor 1 had the highest correlation (r = 0.808, P = <0.001) with GP factor 1. However, it has a weak correlation with other GP factors. Patient factor 2 correlated well with all GP factors, meanwhile, patient factor 3 had a moderate correlation with 2 GP factors and the lowest correlation with GP factor 2. “I have had problems with my weight and hypothyroid- viewpoints, these patients strongly feel that health care is mis- ism since birth and even though I am told to eat right treating them. and despite doing so, you are criticized that you do not. One patient said: Throughout my whole childhood, I have eaten according to the plate model but I am still not properly treated.” I received documentation about a gastric bypass when I sought care for a urinary tract infection. They only think This patient explained that she felt criticized by her envir- that I have to train more, eat a low-calorie diet or should onment and although she felt that she was not treated ad- have a gastric bypass. You do not get help or support for equately, she understood how difficult it is to treat obesity. anything else. Factor 2 (patients): suffering from obesity for a long Factor 3 (patients): do not think that obesity has an time but do not blame health care providers impact on the quality of life and do not think they need any help Seven patients with obesity highlighted that early childhood is the time when food- and exercise habits are developed and Five patients believed that obesity does not affect the quality that there is a hereditary component. These patients confirm of life and that it is not a hereditary condition. Although they that obesity affects their quality of life. They believe that doc- are aware of their condition, they do not think they need tors have sufficient knowledge about obesity and that they treatment, and in contrast to other viewpoints, they do not receive support from health care providers. One patient said: think that obesity is a lifelong disease. One patient said: Downloaded from https://academic.oup.com/fampra/advance-article/doi/10.1093/fampra/cmab169/6505219 by DeepDyve user on 18 January 2022 Family Practice, 2022, Vol. XX, No. XX 5 Table 4. Statements where the different patients and GP factors agreed and disagreed on most. Group and factor number Significantly loaded statements Z-Score Patients factor 1 25. The public judges individuals with obesity 1.617 41. Health care providers treat patients with obesity worse than those without 1.516 27. To keep the weight stable after weight loss is difficult 1.384 2. Individuals with obesity are lazy −1.830 3. Obesity is a person’s own choice −1.941 42. Individuals with obesity do not want to lose weight −2.061 Patients factor 2 27. To keep the weight stable after weight loss is difficult 1.900 25. The public judges individuals with obesity 1.573 14. Obesity is a disease with several different causes 1.474 10. Snacks eating do not lead to obesity −1.435 8. Individuals with obesity have healthy food habits −1.462 26. To lose weight is easy −1.960 Patients factor 3 21. Physical activity improves health regardless of weight 1.857 1. Obesity can be prevented 1.569 44. Use of certain drugs leads to obesity 1.445 33. Obesity is a lifelong disease −1.522 13. Obesity is more common among people with higher education and income −1.584 26. To lose weight is easy −1.778 GPs factor 1 21. Physical activity improves health, regardless of weight 2.019 27. To keep the weight stable after weight loss is difficult 1.637 44. Use of certain drugs leads to obesity 1.360 42. Individuals with obesity do not want to lose weight −1.529 26. To lose weight is easy −1.627 13. Obesity is more common among people with higher education and income −1.807 GPs factor 2 21. Physical activity improves health, regardless of weight 2.079 14. Obesity is a disease with several different causes 2.052 28. Early childhood is the time where food- and exercise habits are developed 1.323 24. Alcohol consumption does not increase the risk of weight gain −1.688 5. Obesity is not hereditary −1.914 22. Stress does not increase the risk of weight gain −2.001 GPs factor 3 21. Physical activity improves health, regardless of weight 1.996 27. To keep the weight stable after weight loss is difficult 1.860 25. The public judges individuals with obesity 1.594 26. To lose weight is easy −1.742 32. 5–10% weight loss is not enough to live longer −1.849 13. Obesity is more common among people with higher education and income −2.014 The table shows the similarities and differences between the patient factors and GP factors. Among the patients, many personal statements were ranked highly. Among the GPs, medical facts about obesity were ranked highly. The majority disagreed with statement 26 and the majority agreed with statement 27. All GP factors and 1 patient factor agreed the most with statement 21, meanwhile 2 patient factors and 1 GP factor ranked statement 25 very highly. I think obesity depends on many things, both medications Factor 2 (GP): believe that obesity is hereditary and but also life situation. I think that if you look backward an eating disorder and look when you became obese, you can relate it to Four doctors believed that obesity is an eating disorder, as something that happened during that time. well as a hereditary condition. They agreed the least with the statement that people with obesity are negatively judged and disagreed the least with the statement that losing weight is easy. Factor 1 (GP): understand the patients and believe that health care provides insufficient support Factor 3 (GPs): obesity is not a lifelong disease but Ten doctors believed they have insufficient knowledge about it is difficult to lose weight obesity and that health care providers treat the patients with obesity worse than those without obesity. There is a certain Seven doctors believed that patients with obesity have a understanding for these patients. Distinguishing for this view- healthy lifestyle and that it is sufficient to change food habits point is that they are not sure whether there is an effective to lose weight. However, they do not have an opinion re- treatment for obesity. garding whether weight loss increases the quality of life or Downloaded from https://academic.oup.com/fampra/advance-article/doi/10.1093/fampra/cmab169/6505219 by DeepDyve user on 18 January 2022 6 Doctors and patients’ perspectives on obesity whether exercise leads to weight loss. Distinguishing from the almost all other viewpoints did, except GP factor 3. Patient other viewpoints, they believe that obesity is not a lifelong factor 3 had the lowest correlation with all GP viewpoints, disease. especially with GP factor 2, who strongly agreed on obesity as an eating disorder and strongly agreed on obesity as a heredi- tary condition. Obviously, this group do not consider obesity Discussion as a chronic metabolic disease. Several studies have shown the importance of good com- Strengths and limitations munication between GPs and patients. In our study we We used a method that is well established in the social sciences, focussed on the different perspectives on obesity both but remains a relatively novel approach in medical sciences. within and between GPs and patients. Our findings show The major strength of this method is that Q-methodology al- some differences and similarities in ranking between the lows statistical interpretation of qualitative data and provides distinguishing statements for the patients and GPs, leading a powerful method to investigate differences and similarities to 6 different factors on obesity. Three factors from patients in viewpoints between doctors and patients regarding their and 3 factors from GPs were considered important in this condition. study. There are some limitations. Selection bias may have been introduced. The GPs who participated may have been more Comparison to existing literature interested in obesity and were motivated to make a change, Patient factor 1 underlined their belief of the importance of compared with the GPs that did not choose to participate. combining diet and exercise for an effective weight loss Secondly, the participating patients may have had more nega- even though other studies suggest that also behavioural tive experiences with health care providers and they may strategies such as self-monitoring are required for a suc- experience a more impaired health and participated for this cessful result. Besides that, this group agreed strongly on reason. the statement that health care providers treat patients with obesity worse than those without obesity, which the other Conclusions groups did not. This patient factor had a high correlation with GP factor 1. The correlation between patient factor 1 We showed that viewpoints on obesity are different, both and the other GP factors was much lower, which may be within and between patients and GPs. A patient may have explained by the fact that these GPs did not highlight state- completely different viewpoints regarding his/her condition ments that were associated with discrimination and lack of than the GP. Some GPs show viewpoints that are not sup- knowledge about obesity. Instead, they highlighted medical ported by the current knowledge, such as considering obesity facts about obesity, which these patients did not take into mainly as a lifestyle problem, rather than a chronic disease. consideration. In addition, our findings show that a considerable number of In patient factor 2, this group seemed to have struggled patients feel stigmatized because of their obesity, and experi- with obesity for a long time and they were unsure whether ence impaired quality of life. For these reasons, awareness of health care providers could do more for them. This patient these differences is relevant for clinical practice; if the GP and group believed that patients with obesity have unhealthy the patient are able to find mutual viewpoints about obesity, eating habits, and they were neutral about their knowledge patient satisfaction will improve and a treatment and/or sup- regarding obesity-associated health risks. They confirmed port strategy will be more effective. that doctors have adequate knowledge about obesity, and did not feel that they were treated any differently than patients Funding without obesity. This is in line with studies in which patients with obesity reported positive experiences with health care. The study was funded by departmental resources. They also confirmed that obesity has an impact on quality of life, thus confirming previous research regarding the re - Acknowledgements lationship between obesity and a decreased quality of life. This viewpoint had a similar correlation with all the GP view- We thank the professionals at the Obesity Unit at the Örebro points, which means that they share similar opinions about University Hospital for their support with the review of the these statements. Q-sort statements. Patient factor 3 differed from the other patient factors and showed a believe that patients with obesity neither need treat- Ethical approval ment, nor have an impaired quality of life. This shows that there are patients with obesity who are less affected by their Ethical approval was granted by the Etikprövningsmyndigheten condition. These patients strongly disagreed on the statement Uppsala (Dnr 2019-04756). that patients with obesity suffer from impaired mental health, although previous studies demonstrate that obesity and de- Conflict of interest 19,20 pression often coexist and are interrelated. They also dis- agreed on the statement that obesity is a hereditary condition, None declared. and they were neutral about obesity as being a persons’ own choice, as well as that they agreed on that patients with obesity Data availability have healthy food habits. These patients neither seemed to feel bad about having obesity, nor did they want any help The data underlying this article will be shared on reasonable and nor did they consider obesity as a lifelong disease, which request to the corresponding author. Downloaded from https://academic.oup.com/fampra/advance-article/doi/10.1093/fampra/cmab169/6505219 by DeepDyve user on 18 January 2022 Family Practice, 2022, Vol. XX, No. XX 7 11. Akhtar-Danesh N. Qfactor: a command for Q-methodology anal- References ysis. Stata J. 2018;18(2):432–446. 1. Burki T. European Commission classifies obesity as a chronic dis - 12. Zabala A, Pascual U. Bootstrapping Q methodology to im- ease [published online ahead of print, 2021 Jun 1]. 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Journal

Family PracticeOxford University Press

Published: Jan 12, 2022

Keywords: obesity; client satisfaction; quality of life

References