Communication about weight‐related issues with adult patients with obesity in general practice: A scoping review

Abstract Background Primary care providers see patients with obesity in general practice every day but may be challenged regarding communication about obesity. The research question of this study is: how do general practitioners and general practice staff and adult patients with obesity communicate about weight‐related issues? Methods A scoping review approach was used, searching PubMed, Scopus and CINAHL for peer‐reviewed studies – of both quantitative and/or qualitative study designs, and published between 2001 and 2021. Results Twenty articles were included. The weight‐related issues discussed were by far physical issues, and only one study mentioned psychosocial issues. Most of the included studies contained information on who initiates the communication, how the weight‐related issues are addressed and handled, and also obstacles and challenges in relation to the communication. The studies lacked information of when the weight‐related issues are addressed and differences in views and experiences when discussing weight‐related issues in general practice. Conclusion Studies with the main focus communication about obesity and overall health in general practice are needed. Findings also indicate, that non‐stigmatizing communication tools and guidelines are needed on this area to promote these types of conservations.


| Eligibility criteria
The making of the eligibility criteria took its starting point in the "PCC" mnemonic consisting of the Population, Concept, and Context. 21In this review, the population is adult people living with obesity, the concept is communication about weight-related issues, and the context is general practice.An overview of the definitions and eligibility criteria of this scoping review is presented in Table 1.

| Information sources and search
To ensure access to a diversity of studies with both quantitative and/ or qualitative study designs, the online databases PubMed, Scopus, and CINAHL were searched.All final searches were conducted on Monday 6 December 2021.The before mentioned online available review protocol shows an example of a complete search on PubMed.
For each of the included studies for data extraction, the reference lists were screened for additional studies for inclusion.
The search strategy for all three databases was developed in cooperation with a health science librarian, and the final search strategy was examined by another health science librarian.

| Selection of sources of evidence
All records were uploaded to EndNote and afterward Covidence where the duplicate removal tools were used by both programs.The screening was done by the first and senior author using Covidence and performed independently by two reviewers with different professions.Titles and abstracts were independently read and assessed in the first round of exclusion, based on the predefined inclusion criteria pre-specified in the review protocol.The remaining studies which seemed to meet or maybe meet the predefined criteria were read in full-text in the second round of exclusion.Reasons for exclusion of full-text papers not meeting the inclusion criteria were recorded for use in the flowchart.After the second round of exclusion, reference list and studies found when making the initial searches were looked through, and no additional studies were found relevant by agreement of the two authors doing the screening.

| Data charting process and data items
Data extraction was done by the first author using the data extraction tool developed by the authors made by modifying the standardized tool made by Joanna Briggs Institute (available in the review protocol 21 ).The data charting included citation details, origin/country of origin, aim(s), study design, participants' details, methodology and main findings related to the scoping review questions(s).[28] Dealing with weight-related issues as topic.c Not dealing with weight-related issues as a topic.

Context
General practice/general practitioner/general practice staff The terms used for general practice, general practitioners and general practice staff shows great diversity and overlap internationally.5,29   In general practice from all over the world.
General practitioners and all general practice staff.
Not in general practice.
In Table 2  The WHO definition of BMI is used for people 20 years and older.To be pragmatic, this review defines adults as 18 years or older.
b BMI, Body Mass Index.
In the a priori protocol, it is mentioned that people with BMI <30 are excluded from the review.When conducting this review, it was clear that patients with overweight often could not be clearly separated from the group of patients with obesity, and therefore this scoping review also included studies dealing with both patients with overweight and obesity.
not if they were only mentioned in for example, a demographic table describing the population.The data charting also consisted of a qualitative descriptive content analysis approach to extract the data about the communication.

| Critical appraisal of individual sources of evidence
The validated tool for assessment of study quality, the Quality Assessment Tool for Studies with Diverse Designs (QATSDD), 30 was used for the quality assessment because of the suitable fitting for both quantitative, qualitative and mixed-method studies.The QATSDD uses a 16 item scoring system with a Likert scale (0-3 points) for each item.

| Synthesis of results
The data were analyzed and presented as described in the protocol.
Also, the descriptive and numerical analysis and summary table with information on the extent and nature of the included studies was developed, and in relation to this the weight-related issues were further categorized into greater categories, making it more accessible.A table with a presentation of the quality assessment score was developed.

| Existing studies on the topic
A total of 8062 records from PubMed, CINAHL and Scopus were identified, and after using different methods for duplicate removal, 4682 records were screened on title/abstract level by the two reviewers.182 articles were screened for eligibility by the same two reviewers by reading full text.This resulted in 20 articles qualifying for data extraction etc (Figure 1).Tables 2 and 3 31 which is automatically made by Covidence, was downloaded and hereafter adjusted manually to fit the approach of this scoping review.
T A B L E 2 Overview of the study characteristics of the included studies.

Main findings
Reference number 32

Main findings
Author(s): Gillian L. -561 3 quantitative (15%).Most of the studies were conducted in USA (n = 10, 50%) and secondly in United Kingdom (n = 3, 15%).All of the included studies dealt with general practitioners (n = 20, 100%).Only a very small proportion of the included studies focused on a specific patient subgroup (n = 3, 15%).The majority of the studies dealt with both overweight and obesity (n = 14, 70%), and the rest of the studies solely dealt with obesity (n = 6, 30%).Because of the great amount and diversity of weight-related issues, the authors have categorized these items in major categories in Table 3, which reveals that the most frequent categories mentioned in the studies were "impact on general health" (n = 18, 90%), "diabetes and prediabetes" (n = 15, 75%), "hypertension and impact on blood pressure" (n = 14, 70%), "hyperlipidemia and affected blood lipids" (n = 8, 40%) and musculoskeletal problems (n = 8, 40%).Only one study held information of psychosocial (i.e., depression) weight-related issues (n = 1, 5%).The study characteristics regarding the subdivisions of communication of this review will be described in details in Section 3.3.

| Quality of the studies
The Quality Assessment Tool for Studies with Diverse Designs (QATSDD) 30 was used (Table 4).In general, the quality of the included studies, and therefore literature on the topic differed from relatively low quality to relatively high quality.Most of the included studies got about half of the potential quality points.In general, the studies especially got a low score, because of no explicitly stated research question.Also, many of the studies did not mention if the sample size of the study was considered to fit the analytical requirements.Finally, few studies used user involvement in design.On the other hand, the studies got a high score because of statements of an explicit theoretical framework and descriptions of research setting and of procedure for data collection.

| Communication about weight-related issues
This section of the results will present the different parts of the communication about weight-related issues.An overview of the included articles with information about content of examples of the different subcategories of communication is presented in Table 5.In the following headings the most frequent themes of the extracted examples from the studies will be presented and gathered with quotations to the different included studies, giving an insight of the diversity of the difficult and complex field of communication about weight-related issues in general practice.

| Timing for addressing weight-related issues
Only one study held information regarding when the weight-related issues are addressed in general practice 41 (Table 5).This example T A B L E 2 (Continued)

Methodology Main findings
Patients in the study only with obesity or both overweight and obesity included: Both patients with overweight and obesity Types of weight-related issues: (Their weight) is an issue where it's clearly impacting on their (health), clinical weight issues, obesity feeds into (their other health issues), patients' excessive weight was impacting directly on their health for patients with overweight and obesity Note: Because some of the studies uses the same abbreviations for different concepts, the specific abbreviation used in the different studies will be stated in the table for each study.Abbreviations: GP/GPs, General practitioner(s); GP staff, General practice staff; NA, Not applicable.
T A B L E 3 Descriptive numerical analysis and summary of the included studies (modified from "tabular presentation of data for a scoping review," 11.2.9, JBI Manual for Evidence Synthesis 21 ).was referring to the topic addressed after a blood test, where a patient with obesity said: "I did a blood test and found out that my cholesterol had gone up… That is when we spoke about the weight issues." 41

| Addressing weight-related issues
All studies but one held information on how the weight-related issues are addressed [32][33][34][35][36][37][39][40][41][42][43][44][45][46][47][48][49][50][51] (Table 5). Some sudies held general examples of positive ways to address the topic.As an example the topic could be addressed by discussing the risks of developing or having weight-related issues as a motivating factor for change and improvement of risk factors for the patients' health.[34][35][36][39][40][41]45,[47][48][49][50] In addition, some studies mentioned the communication of weightrelated issues in general practice as having focus on general health and wellness rather than weight loss.40,46,47,51 On the other hand, many studies also documented the negative experience a discussion of weight-related issues in general practice can be.This could for example, be that the issue of the patients' complaints was generally attributed to weight by the primary care provider, irrespective of the specific cause.32,50 Likewise, some studies mentioned the central topic of stigma in relation to the weight-related conversations.44,50 Also, some studies highlighted the view of raising the issue as an general practitioner obligation.50,51 In addition to the above mentioned themes, primary care providers used direct language in different manners in the included studies, 39,45,46,49 for example, in a paternalistic way of addressing the issue to the patient: "You got an atomic bomb here.Now you go figure it out." 39 and "… then I woutell him: 'It won't work like this! Something has to change!' (GP14)."46 Some studies also highlighted the reference to possible family history of chronic conditions/weight-related issues as a way of addressing the topic.36,44,48 Finally, one study used a screening tool for estimating patient risk of having weight-related health problems.44 T A B L E 4 Overview of quality assessment of the included studies.

Citation details
Quality rating (score/%) Note: QATSDD uses a 16 item scoring system with a Likert scale (0-3 point) for each item.Some items only apply to quantitative or qualitative studies (highest score possible for qualitative and quantitative 42 points).Mixed method studies qualifies for both quantitative and qualitative quality assessment and therefore has a total possible score of 48.The score of each study out of total possible and also in percentage of total possible can be viewed in the table.The numbers/counts in the table is number of the 20 included studies dealing with GPs and/or GP subgroups. b The number in the table is number of the 20 included studies dealing with communication about weight-related issues.The weight related issues in the table are major categories which the authors of this review found most suitable to describe the weight-related issues mentioned in the included studies.The headings of columns of this table is the original division of subcategories when communicating obesity related to the review question-also mentioned in the online available review protocol.
b During consultations/not specified: in all the included studies communication about weight-related issues occurred, but when is often not specified-for example, when taking anamnesis, making the clinical examination or when talking about the treatment of the patient's symptoms.
[35]41,43,45,48,49 Providers also used changes of or addition of medications.36,40,43 Lastly, also the use of referral to specialists was used as tools to handle weight-related issues in general practice, for example, referral for diabetes group therapy or an educational program, 32,34 external weight management programs or local resources, 33,34,42,44 dieticians or nutritionists, 33,38,39,43,45 chronic disease nurse counselors or practice nurses, 33,38 obesity medicine specialist or referral or encourage to bariatric surgery.33,43 Differences in general practitioners' or general practice staffs' and patients' views and experiences of communication about weightrelated issues.
Only one study held information on this topic 43 (Table 5): "When talking about weight or weight management with their patients who have osteoarthritis and obesity, primary care physicians were much more likely than patients to report discussing the effect patients' weight has on their osteoarthritis and overall health, helping patients set goals to improve their weight and understand why they have excess weight, and making patients aware of medications that will help them lose weight…." 43

| Obstacles and challenges in relation to communication about weight-related issues
Most studies held information on obstacles or challenges in relation to communication on this topic [32][33][34][35][37][38][39][40][41][42][43][44][45][46][47][49][50][51] (Table 5). Overwhelmingy, it was the primary care provider who was seen as an obstacle for communication on this topic.One major obstacle mentioned by the studies was lack of time.37,38,40,41,43,44,46,47,51 Also, one consistent topic was primary care providers looking down on patients and thinking they were not willing to improve or that they lacked motivation.32,38,43,46,47,49,51 In relation to this, the primary care providers often informed the patients of their weight status but did not give additional information.39,45,50 In addition, primary care providers could show signs of disapproval.32,45,49 The providers generally found it difficult to shift the attention to the weight or raise the issue in general, 33,38,44,50 for example, in acute situations.34 Sometimes the providers argued that patients already were aware that they had obesity but were not interested in starting a conversation about it.44,51 Also, the primary care provider felt the patients did not present obesity as the main cause of the medical condition.44,50,51 Primary care providers could perceive communication on this topic as a risk of offending new patients in the clinic 34,35,46 or offending the patients in the clinic in general. 38,51 Sometimes the primar care provider's own weight was perceived as an obstacle or having an impact on the conversation.35,50 Finally, the providers found that they lacked training in obesity management, 37,51 had a general lack of knowledge and skills regarding how to address obesity, 40,51 for example, before morbidity sets in.38 Finally, primary care providers felt a lack of treatment possibilities, and missing material on the topic practitioners and very few studies focused on a specific patient subgroup with obesity.The most frequent major categories of weight-related issues were "impact on general health," "diabetes and prediabetes," "hypertension and impact on blood pressure," "hyperlipidemia and affected blood lipids" and musculoskeletal problems.
Only one study mentioned psychosocial weight-related issues and none mentioned cancer as topics of discussion.The studies were in general of medium quality when doing quality assessment.As regard the topic of communication, this scoping review found multiple examples regarding the "who initiates"-, "how they are addressed"-, "how are they handled"-and "obstacles/challenges"-sub-questions.
Few studies held information regarding "when they are addressed" and "differences in views."As mentioned above, this review gathered plenty of information regarding who initiates communication about weight-related issues in general practice.All of the included studies mentioned the general practitioner or general practice staff initiating the discussions.Only six of the studies showed the patient initiating the discussions.One of the included studies had initiation of weight discussions as main focus stating general practitioners more often than patients initiates these discussions and clinical relevance as the most notable way of achieving a constructive dialog which fits the findings of this review. 48This review included many studies demonstrating how the weightrelated issues are addressed in general practice with great diversity.Firstly, many of the included studies held information of using weight-related issues as a motivating factor for patient change and reduction of risk on one's health.One newly published study using the ACTION-IO data for analysis identified the significantly associated variable with motivated people with obesity as "important goal as part of weight management: To reduce the risks associated with excess weight/prevent a health condition." 52This emphasized the use and importance of the use of weight-related issues as a motivator when discussing this topic in general practice.Secondly, some studies in this scoping review held information on the primary care provider using direct language, including use of a paternalistic way of addressing the weight-related issues.In the studies the patients also argued discomfort with direct paternalistic language.Other literature also highlighted the importance of patient centered care using for example, shared decision-making instead of paternalism. 53Lastly, the authors of this article found one new pilot study explaining the use of a screening tool for patients having weight-related issues. 44Also, this review included many studies with information on how weightrelated issues are handled.In general, this review highlighted the already known use of general recommendations of weight loss or more specific advice about exercise or diet modifications.This kind of intervention seems to induce clinically meaningful weight loss in the literature. 54This scoping review also showed a great use of referral to specialists, for example, weight management programs which seems to be an effective way depending on the duration. 55Few of the studies included referral to bariatric surgery.However, it is important to underline the effectiveness of this way of severe obesity management. 56The last subdivision of communication was obstacles and challenges in relation to communication about weight-related issues with patients with obesity in general practice.One great obstacle reported was lack of time, which is also mentioned as an important barrier for effective obesity care in other literature. 57is scoping review also found a great diversity of ways in which the primary care providers have biased a general negative view of and impression of the patients.The before mentioned supports the great amount of literature about stigmatization of patients with overweight and obesity in health care, 11 which also tends to have a negative effect on health behavior. 58Finally, the providers missed training and knowledge on obesity communication.This is also known in the literature where the use of motivational interviewing or the 5 As framework is known but still poorly understood as to the effect on patient outcomes. 59One major knowledge gap identified when conducting this scoping review was what despite the fact that identifying 20 studies containing information on communication about weight-related issues with adult patients with obesity in general practice, not one of the included studies had this topic as its main focus.This also shows in the titles and aims of the included studies in Table 2 and also the fact that the concept of "many examples" in Table 5 of this scoping review only needed to be minimum three examples in the included studies.To ensure the validity on the research in this area, future studies need to focus more exclusively on this topic.A surprising and major finding of this study, was that only one study held information on discussion of psychosocial issues-more precisely depression.
Furthermore, none of the studies mentioned cancer in the weightrelated discussions even though it has been known for many years as a co-morbidity related to overweight and obesity. 4The main focus of the included studies was clearly the physical weight-related issues of patient with obesity.This calls for future research to also highlight the topic of psychosocial issues of patients with obesity, for example, depression, anxiety, eating disorders, quality of live etc.Also by Joanna Briggs Institute 21 as starting point and followed the five stages of conduction 22,23 which was performed systematically and stringently as described in the protocol developed a priori.A major search string was developed in corporation with a health science librarian which led to the narrowing from 4862 studies to 20 included studies after full screening done independently by two of the reviewers leading to agreement.Also this review examined a great diversity of data extracted (Table 3), providing a considerable overview of the existing literature on the topic.On the other hand, this scoping review did not include gray literature as scoping reviews often but not always include.However, the aim of this scoping review was to explore the peer-reviewed published literature to explore the higher quality scientific articles on this topic.This scoping review identified twenty peer-reviewed qualitative, quantitative, and mixedmethod studies concerning communication about weight-related issues with adult patients with obesity in general practice.The studies mostly had an acceptable quality.The studies held almost no information on when the weight-related issues are addressed, and if there were differences general practitioners' or general practice staff's and patients' views and experiences when discussing the topic.Many of the studies held information about who initiates the discussion, how the weight-relate d issues are addressed and handled and also obstacles and challenges when discussing the topic.Even though 20 studies on the topic were identified, none of the studies had the topic of "weight-related issues" as a central theme, and therefore future research needs to make this a main focus to one or multiple of the sub-questions regarding communication of this scoping review.The included studies in general focused on physical weight-related issues and neglected the psychosocial weight-related issues-this also need to be implemented in future research.Finally, future research on this topic need to focus on the differences in primary care provider and patient view of discussing the topic for example, making direct LINDBERG ET AL.T A B L E 1 Overview of definitions and eligibility criteria of this scoping review.people (≥18) years, both sexes.Only concerning children in general (age in years <18) communication.Not dealing with communication as a topic or only focusing on nonverbal communication.
respectively give an overview of the study characteristics and descriptive numerical analyses and summary of the 20 included studies.The majority of the studies were published after 2014 (n = 13, 65%).As regarding study design, 12 studies were qualitative (60%), 5 mixed-method (25%) and F I G U R E 1 Flow diagram.All screening and inclusion of studies presented in the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) flow diagram,

14 Weight
GPs or GP staff subgroups represented and number a GPs: 20 GP staff subgroups: 6 Patient with obesity subgroups and number Low-Income African American women who Successfully lost weight: 1 Patients with comorbid chronic pain: 1 Black women: 1 Number of studies dealing patients with obesity and/or overweight Only dealing with patients with overweight: 0 Only dealing with patients with obesity: 6 Dealing with both patients with overweight and obesity: containing information about the subdivisions of communication When/in which part of the consultation the weightrelated issues are addressed: 1 Who initiates the communication about weight-related issues: 17 How the weight-related issues are addressed: 19 How the weight-related issues are handled: 16 (Continues) LINDBERG ET AL.
practitioners' or general practice staff's and patients' views and experiences of communication about weight-related issues: 1 Obstacles or challenges in relation to communication about weight-related issues: 18 a

5
Overview of examples of the different subcategories of communication in the included studies.
Few examples: one to two examples of the communication subcategory in the included study.Marked with light gray.d Many examples: >2 examples of the communication subcategory in the included study.Marked with darker gray.566 -LINDBERG ET AL.
, future research need to focus on the relation between cancer and overweight and obesity.As mentioned earlier in the discussion, primary care providers mentioned in multiple of the included studies lack of time as a major barrier for initiating and shifting the attention to communication with patients on this topic.One study interestingly did a pilot study of a risk tool of patients having weight-related issues and mentioned the effectiveness of using such a tool.44More research on this topic is needed to explore ways to decrease stigma in patient-provider communication in general practice where lack of time is a central theme.Finally, insights into both the patients' and primary care providers' views of this specific encounter in a reasonable time after the encounter is needed, which could be studied through direct observation of the clinical encounter.This would lead to a more nuanced insight into the clinical encounter with minimal risk of recall bias and also make way for a more precise understanding of differences in the patients' and primary care providers' views on this topic.This scoping review is presumably the first study making a clarification of what is known about communication about weight-related issues in general practice with adult patients with obesity, gathering key concepts and knowledge gaps for researches of interest and future research.The methodology of this scoping review took the description of conduction of scoping reviews

Citation details Study aim (s) Country Study design Participants details Methodology Main findings
554-T A

B L E 2 (Continued) Citation details Study aim (s) Country Study design Participants details Methodology Main findings
to best practice on how senior medical students and their GP tutors can acquire the role of legitimacy and role of competency required for effective practice was conducted in the study.tantfactor in promoting weight loss in low-income, African American women.Patients may benefit from their PCPs drawing connections between obesity and weightrelated medical conditions and enhancing intrinsic motivation for weight loss.(Continues)LINDBERG ET AL.T A B L E 2 (Continued) Focus group study PCPs use a variety of strategies to communicate with their patients about weight loss.A part of PCPs already use patient-centered approaches to communicate with their patients about weight loss, suggesting that future weight counseling interventions should be tailored to build upon this strength.: Title: "There's always something else": Patient perspectives on improving the implementation of obesity guidelines in general practice Author(s): D. Mazza, E. McCarthy, N. Singh, M. Carey, L. Turner, M. Harris Date of publication: 19 September 2020 Journal, volume, issue, pages: Obes res clin Pract.Sep-Oct 2020; 14(5):437-442 Describe patient perspectives on the implementation of obesity guidelines in general practice.Australia Qualitative Sample size: 40 Age: Range 46-84 Sex: 22 female and 18 Geographical location: Melbourne GPs or/and GP staff subgroup(s): General practitioners (GPs Patients with obesity subgroup(s): NA Patients in the study only with obesity or both overweight and obesity included: Both patients with overweight and obesity Types of weight-related issues: Diabetes, cholesterol had gone up, blood pressure was directly related to weight, health Semi-structured telephone interviews It is of great importance to take into account patient perspectives on obesity management in general practice in order to improve health outcomes.This study provides valuable insights into how people living with obesity can be better managed.Interventions should also include strategies to help patients maintain motivation in making lifestyle changes to support healthy weight loss.556 -LINDBERG ET AL.T A B L E 2 (Continued) LINDBERG ET AL.T A B L E 2 (Continued) 558 -LINDBERG ET AL.T A B L E 2 (Continued) T A B L E 2 (Continued) 560 -LINDBERG ET AL.T A B L E 2 (Continued) LINDBERG ET AL.