Practitioner and patient experiences of giving and ...

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Practitioner and patient experiences of giving and receiving healthy eating advice Jane McClinchy, Angela Dickinson, Duncan Barron, Hilary Thomas

Jane McClinchy is Principal Lecturer in Dietetics at the University of Hertfordshire; Angela Dickinson is Senior Research Fellow, Older People’s Health, at the University of Hertfordshire; Duncan Barron is Senior Research Fellow, Patient and Public Involvement, the University of Brighton; Hilary Thomas is Professor of Health Care Research at the University of Hertfordshire Email: [email protected] DH, Social Services and Public Safety, 2012). In England and Wales, ‘Change 4 Life’ aims to ‘prevent people from becoming overweight by encouraging them to eat better and move more’ (DH, 2011b). Similar campaigns have been developed in Scotland (‘Take on life one step at a time’ (Healthier Scotland, 2008)) and Northern Ireland (‘Get active, get a life’ (Public Health Agency, 2009)).

Public knowledge

This article explores the content of discussion by patients and practitioners where they were invited to talk about food and diet. A qualitative methodology using focus groups was employed within one Primary Care Trust in the east of England. Patients described their desire for access to nutritional guidance in primary care and their feelings of powerlessness when following dietary advice. Primary care practitioners discussed their experiences of giving information alongside their scepticism about patients’ adherence to dietary advice. Without prompting from the interviewer, patients and practitioners independently chose weight management to illustrate their experiences. Frustrations were expressed by patients and practitioners groups who felt unmotivated to seek or give information respectively on weight management.

Research in the UK as well as overseas suggests that the public are knowledgeable about public health nutrition policies (Attree, 2006; Worsley 2006; Lake et al, 2007; Bouwman et al, 2009). However, the food choices that people make for themselves and their families are often influenced by structural concerns (e.g. income (Attree, 2009)), ethnic and cultural issues (O’Dea, 2008; Ristovski-Slijepcevic et al, 2008), and social issues (e.g. class (Coveney, 2005; Lake et al, 2007)). Furthermore, attitudes towards the concept of healthy eating (Bouwman et al, 2009) and body fat (i.e. adiposity (Lake et al, 2007)) are also significant. In 2006, the General Medical Services contract offered financial reward to doctors whose patients with conditions such as diabetes and hypertension showed improved outcomes, and rewarded the recording of the presence of obesity across their caseload. No additional financial incentive for GPs to provide weight management services has been implemented since then (NHS Employers, 2013). However, the NHS requires practitioners to ‘make every contact count’ with their patients, ‘to maintain or improve their mental and physical health and wellbeing where possible, whatever their speciality or the purpose of the contact’ (DH, 2012). In addition, research evidence suggests that there is a lack of skills available for supporting weight management in primary care (Butler et al, 2013). Doctors may also have an ‘anti-fat bias’ towards obese people, thereby compromising their care (Sabin et al, 2012).

KEY WORDS

Perceptions of obesity

Abstract

w Healthy eating w Patient experiences w Obesity w Practitioner experiences

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There is also a body of research indicating that public health nutrition campaigns may be adversely affected by a negative focus on obesity in health care and in the media (Maclean

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hronic diseases such as diabetes, cardiovascular disease and cancer contribute toward premature deaths in the UK (World Health Organization (WHO), 2013). Lifestyle choices such as a healthy, balanced diet are necessary to prevent as well as manage these diseases (WHO, 2008). However, as obesity is linked to the development of chronic disease, policies often focus on weight management, alongside encouraging the consumption of a healthy, balanced diet (WHO, 2012). This relationship is reflected in government policies (Food Standards Agency (FSA), 2013a; 2013b; Department of Health (DH), 2013) and in guidance given by consumer health organisations (CHOs) (Boyle et al, 2009; Diabetes UK, 2011; National Osteoporosis Society, 2011; British Lung Foundation, 2012; British Heart Foundation, 2013), where healthy eating information is frequently given alongside weight management advice. Although government policies do include healthy eating information, the rise in the incidence of obesity in the UK has resulted in an increased focus on weight management within UK public health nutrition campaigns (Scottish Government, 2010; DH, 2011a; Public Health Wales, 2011;

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Perceptions of healthy eating There is limited research exploring practitioner perceptions of healthy eating, and much that exists focuses on weight management. For example, the effectiveness of weight management advice may be hindered by ineffective training (Hankey et al, 2004; Jochemsen-van der Leeuw et al, 2011; Parker et al, 2011; Butler et al, 2013) and perceptions that the advice will be ineffective (Franc et al, 2009). Interestingly, Epstein and Ogden (2005) found that GPs in London did not feel that primary care was the best place to provide weight management support, believing that patients should manage their weight problems themselves. Therefore, the limited research base and divergence of views and beliefs of patients and practitioners when compared with public nutrition policy suggests a need for further research, using a qualitative exploratory methodology. This article explores what patients and practitioners chose to discuss when invited to talk about their experiences of nutritional advice in primary care.

Method This article presents a part of a larger study exploring primary care practitioner and patient experiences of nutritional information leaflets in primary care (McClinchy et al, 2011). A detailed description of the design and method is available elsewhere (McClinchy et al, 2011). The data collection took place in one primary care trust (PCT) (described as in the London commuter belt) and an urban area in the east of England, and incorporated a qualitative design using focus groups for data generation.The lead researcher was a dietitian who, at the time of the data collection, was employed by the PCT. Ethical approval for the study was obtained from the Local NHS Research Ethics Committee.

Study design GP practices were contacted on the basis of size and location, to ensure a spread across the area and a balance between rural and urban practices. Practices which held a regular multidisciplinary meeting and were prepared to allow the researcher to

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‘piggy-back’ the meeting for a focus group session (Krueger and Casey, 2000) were invited to take part. Some 7 focus groups (size range 6–13) with a total of 57 primary healthcare professionals (GPs, practice nurses, other nurses and practice managers, including 28 women and 29 men) were held. Consumer health organisations (CHOs) relating to the main topics raised by the practitioners and who were based in the area of the research were contacted to invite potential participants to focus groups. These were either held following on from the main CHO meeting (groups 2, 3 and 6) or convened at a separate time (groups 1, 4 and 5), depending on the preferences of the participants. Six focus groups (size range 4–7) with 30 patients (20 women, 10 men) were held. The CHOs were represented as follows: w The Alzheimer’s society carers support group (group 1) w A local multi-ethnic group (including participants mainly from South Asian and Eastern European groups) (group 2) w A PCT public and patient involvement forum (group 3) w A Diabetes UK support group (group 4) w A National Osteoporosis Society support group (group 5) w A Breatheasy support group (group 6). Focus groups were held separately with patients and practitioners (Kitzinger, 1995). Informed consent was obtained prior to the commencement of each session. The focus groups were moderated by the lead researcher using an interview schedule to guide discussions. The practitioners were asked what nutrition topics were most often covered within a consultation, while the patients were asked about their experiences of nutritional advice in primary care. A research assistant took notes. Groups were audio-recorded and later transcribed verbatim. Data analysis incorporated the process of familiarisation followed by line-by-line organisation of the data, coding and theme explanation (Patton, 2002; Silverman, 2005; Pope et al, 2006). The lead author undertook the initial data analysis and the emerging codes and themes were shared with the other authors. This enabled any differences in interpretation to be resolved through discussion, ensured that all possible sources were included and disconfirming instances relating to codes were identified (Silverman, 2006). The descriptions of the themes and linkages between themes were discussed within the research team. A computer programme, N6® (QSR, 2007) designed for the management and retrieval of qualitative data, was used to assist with data organisation (Seale, 2005).

Findings The findings from the patients and practitioners are presented separately below. Quotes from individual participants are given as examples to illustrate the themes.

Patient findings Patients discussed their experiences by explaining why they wanted nutritional advice from primary care. Patients discussed a wide range of factors that they felt affected what they ate (for example, life stages such as pregnancy and ageing and education) as well as the effect of specific diseases. They also discussed their successes or feelings of powerlessness following receipt of nutritional advice from a primary care practitioner.


et al, 2009). Conversely, Garip and Yardley (2011) suggest that experiencing stigmatisation may help to motivate some people to lose weight. Research exploring patient perceptions of obesity has uncovered a range of viewpoints. Sikorski et al (2011) suggest that although the public are aware of environmental and genetic causes of obesity, they perceive internal factors such as the individual’s own behaviour as being more important in motivating people to adhere to weight management advice. Gender differences may also affect outcomes. For example, Smith and Holm (2011) propose that weight gain for women appears to be related to life course stages such as ageing, while for men it may relate to ‘social obligations’ such as work and career. Research has also found that parents’ perceptions of the causes of obesity in children are complex, tending to cross individual, family, community and societal lines. Understanding these may assist in the development of programmes to support families in the management of young children (Pocock et al 2009).



NUTRITION Individual need for advice Participants described their experiences of receiving nutritional advice in primary care relating it to specific disorders, chronic diseases or life stages and using their life stories to contextualise their need for nutrition information. Often, accounts related to diagnosis with a condition such as diabetes or osteoporosis, or when they received blood test results (e.g. serum cholesterol levels) from their GP. In the example below from the National Osteoporosis Society support group (group 5), a discussion described how patients were given dietary advice following diagnosis with osteoporosis:

‘I was diagnosed after the second wrist break and the doctors sent me over to [the local hospital], where the nurse asked me about eating dairy foods and asked the quantities that I had per week and things like that. She seemed to think [they] were satisfactory.’ (Focus group 5) However, within the other five patient groups, weight management was the first topic to be raised by the majority of participants when initially discussing their experiences of receiving dietary advice in primary care. In the example given below, the participant needed advice from their GP on diet, weight management and diabetes having gained weight during pregnancy:

‘The only experience I’ve had of leaflets in the doctor’s surgery are for losing weight after having a baby—and this is some time ago and I can’t quite remember what it said, but I had tried lots of other methods of losing weight as well … and I’m also interested in diabetes because my father had diabetes; it killed him at the age of 57. And I was afraid it would come to me as well if I didn’t look after myself’. (Focus group 1) Availability of nutritional information


Towards the end of the discussions, three patient groups moved away from discussing their individual needs for nutritional advice and explained how they would like nutritional information to be made more widely available. Common anxieties included the lack of dietary and cooking education in schools and other changes in society. The quotes below highlight one group’s concerns regarding their perception of the lack of time available to educate children about cooking and diet in schools:

‘There’s not enough time … you’re not meeting a target if you’re teaching … there is a small component of it in the National Curriculum, but there’s a big pressure now for, you know, to deal with the basics of literacy, numeracy … so there’s some in science as well about diet but it’s quite small.’ (Focus group 5) Changes in society were also offered as a reason for the increase in obesity in the general population. During discussions about the need for nutrition information, groups highlighted how they felt that changes to society had affected


food shopping, cooking and eating practices and how these had in turn influenced eating habits, culminating in an overweight population:

‘Nowadays, women work as much as men, so it’s convenience. I’m talking about the younger people [who] send out for a takeaway—not as much care is taken as with our parents.’ (Focus group 5) Personal successes and powerlessness Participants who followed a diet for diabetes or for weight management, in particular in groups 1 (Alzheimer’s society), 4 (Diabetes UK) and 6 (Breatheasy), readily discussed their individual experiences. For example, a participant with insulin-dependent diabetes described how their daily meal pattern enabled them to maintain their weight and keep healthy:

‘On the whole, I find that I can live with a reasonable sort of diet, I stay quite slim and the dietitian, apart from a few exceptions, seems to be reasonably comfortable with what I eat, which is based on ... three sensible meals each day with a mid-morning snack and a mid-afternoon snack and usually a cup of tea and a biscuit, or a bit of shortbread or something before I go to bed at night.’ (Focus group 4) Generally, participants’ experiences of following dietary advice related to discussions about how dietary advice adherence affected their weight changes. Another participant explained how they had made successful changes to their diet:

‘I was about a stone overweight and without trying, because I’d got a hiatus hernia, which means I can only eat small meals, I’ve just made the meals smaller, as [other participant] said about potatoes and, you know, halve the amount of potatoes, and I managed to lose the weight without too much problem. And [by] eating more of the more suitable things and not too much potato and bread.’ (Focus group 1) During discussions about experiences of weight management, participants highlighted their feelings of powerlessness and surprise when they found it difficult to control their weight. Phrases such as ‘putting on weight hand over fist’, or ‘it started to edge back up’ were used. Participants spoke on the subject of having difficulty adhering to weight management advice. They made a decision on the basis of whether it would be worth it, or sometimes adapted the advice to fit their own situation. Having found their dietary adherence to be ineffective, this participant decided that following advice was not worth the effort required:

‘I’ve been to Weight Watchers so many times, so in years gone by, I’ve been so many times and lost 2 stone, 3 stone, oh great! And then you think “I’ll just have so and so”, and before you know where you are, the couple of pounds has gone on

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NUTRITION and that is very easy.’ (Focus group 3) All groups gave weight management as an example of situations where they would give nutritional advice. Often this would be related to specific requests from patients. In this case, the nurse explains how giving delivering dietary advice is challenging because patient needs are changing:

Weight management, not healthy diet, is increasingly focused on.

and then in a little while all that weight has gone back on again unless you diet for the rest of your life and, quite honestly, I think you get to the point and you get the age and you just think “I’m not going to do this anymore”.’ (Focus group 6) Participants said that they did not always adhere to the professional advice they were given. Another participant explained how they combined the advice they had been given from a range of different sources, finding that this proved more effective:

‘People have said to me … “well, you’re looking good, how do you do it?” I say, “quite frankly, I take the advice that all the various people give me. I put a little bit of my own intuition into the equation,” and I said “sometimes I eat what I like, as I like it, when I like it but I just do it in controlled portions and I exercise”. And I said “I keep my weight down”.’ (Focus group 4)

Practitioners Practitioners discussed their experiences of giving dietary advice in primary care, often focusing on their concerns about patients’ willingness to adhere to advice.

Giving advice Group sessions commenced with practitioners being asked about situations where they would give nutritional advice. Practitioners often listed dietary advice related to chronic diseases such as diabetes and cardiovascular disease, as well as life events such as pregnancy, sometimes using leaflets to support verbal advice:

‘The two main leaflets I use is the diabetic one when I initially diagnose; they often end up with me, it’s just the beginning, it’s a very simple leaflet from the hospital. The second one I gave is a fibre one, which is on healthy eating. It’s a traffic light, so there are a group of products and ‘eat once a day’

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Dietary advice for diabetes was another common topic that practitioners said they discussed with patients. However, practitioners would often expand on their explanation of how they delivered dietary advice by using weight management as an example. For example, the following quote illustrates how practitioners used behaviour-change skills with overweight patients to increase adherence:

‘The main people I give nutritional advice to are overweight patients and diabetic patients ... With the overweight ones I tend to talk quite a bit about the psychology: a lot of them know what they’re doing wrong but they just can’t stop doing it.’ (Focus group 5) Practitioner advice: effectiveness and adherence Practitioner discussions focused on patient adherence to advice. Practitioners used overweight patients as examples, thereby revealing their frustration with providing weight management advice, a situation which appeared to be a frequent occurrence, as illustrated by the following quote:

‘Those that come specifically because they want to see somebody because they want to lose weight, they’re more motivated. But it’s when you get 6 weeks down the line and they’re still not losing weight and they swear blind they’re eating nothing that you start the struggling and you think, well, where do we go now?’ (Focus group 3) Although discussions often focused on weight management, practitioners sometimes discussed patients other than those needing to lose weight. In the following example, an apparent common occurrence in diabetic clinics is highlighted:

‘I have tested it out at the diabetic clinic because I come in and say, you know, “what did the dietitian say to you?” [They reply] “Well, she said I’m doing fine”, and you can see on the screen “cut down on cakes and biscuits”.The interpretation of what’s been said to them which has been a clear message and they come to me with they are “doing fine”, they never come to me and say “they said I should eat less fat” or “I should stop having chocolate”. They say, “they told me to eat regularly”.(Focus group 8)


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‘Yes, but it is quite a hard area and things tend to change as well, so you get patients through the door wanting to know all about glycaemic index diet at the moment and Atkins diet.’ (Focus group 6)



NUTRITION Practitioners gave examples of the ways they attempted to improve the effectiveness of dietary advice, aiming to encourage their patients to change their behaviour by providing follow up:

‘We can encourage by encouraging people to be weighed, but of course those who need it most are those who never come in, or they come in once and if you’ve told them that they never come in again. The most important thing is to convey to them why it matters to lose weight. That’s probably more important than telling them how to lose it because we don’t actually know that.’ (Focus group 7)


Discussion Both groups explored the need for nutritional advice in relation to weight management. Patients used their experiences to contextualise how dietary advice might be needed more generally. Their accounts demonstrated both successes and feelings of powerlessness regarding implementation of dietary advice. Some practitioners gave weight management advice in primary care and issues of adherence were often cited. However, in half of the patient groups, discussions went further, exploring structural influences on diet and nutrition. Practitioners limited their discussions to their professional practice and management of their own patients. There were countless diet-related topics that the patient groups could have chosen to focus on. Diet and prevention of heart disease is often a topic which features in advice for people with diabetes (Diabetes UK, 2011), but this was not referred to by the diabetes group discussion. Both the Alzheimer’s Society and the Breatheasy support groups (groups 1, 4 and 6) could have focused on the importance of achieving a healthy, balanced diet. However, accounts from these three groups focused on exploration and experiences of weight management. Although public health nutrition policies cover all aspects of a healthy diet, the nutrition campaigns have a particular focus on weight management. This article notes the potential impact that this may have had on the patient and practitioner accounts. Despite the Government clearly stating the role that practitioners have in supporting patients’ health and wellbeing (DH, 2012), the primary care contract appears to have limited emphasis on weight management (NHS Employers, 2013). In addition, modern research suggests that practitioners need to have adequate training and time in order to ensure that lifestyle behaviour change interventions are effective (Butler et al, 2013). In line with other research (Kenner et al, 1999), practitioners referred to a wide range of nutrition-related topics that they would cover in their clinics. However, weight management was discussed frequently as a topic in all practitioner and patient groups, and healthy eating was rarely mentioned. Discussions with patients concentrated on the frustrations of weight management, which was used to contextualise concerns about the feasibility of dietary change and whether it was worth making the changes. Discussions with practitioners moved onto concerns about adherence and


the effectiveness of professionals’ advice. In these discussions, weight management was used as the main example to contextualise practitioner experiences. The frustration and sense of powerlessness around weight management highlighted in both patient and practitioner groups has been widely reported (Hankey et al, 2004; Franc et al, 2009; Garip and Yardley, 2011; Jochemsen-van der Leeuw et al, 2011; Parker et al 2011). Patients discussed weight management both in terms of their own experiences and more generalised concerns about the nation’s health and wellbeing. This contrasted with practitioner discussions, which were concentrated on their patients attending their clinics. A key finding was that weight management was a major subject of discussion in both the patient and practitioner groups, even though participants had not been directed to specifically discuss the topic. Patients discussed the potential impact of structural influences on the ability of the general public to consume a healthy, balanced diet (Attree, 2006; Worsley, 2006; Lake et al. 2007; Bouwman et al, 2009). For example, it was thought that, with the increase in women working, there was less time available to shop and cook.The effect that this may be having on food choices was noted, which is a phenomenon seen in previous research (Charles and Kerr, 1988; Hitchman et al, 2002). Practitioners did not raise these issues, restricting their discussions to the clinical management of individual patients. This finding contrasts with research undertaken by Greener et al (2010), who conducted interviews with overweight patients and with health professionals and policymakers. The overweight patients focused more on their own experiences, while the health professionals discussed wider sociocultural issues and the policy group viewed the issue of obesity from an environmental viewpoint. This divergence may be due to the different populations recruited in the studies. The present study did not differentiate overweight participants, while Greener et al (2010) specifically recruited overweight patients. The focus group discussions may also simply reflect overriding concerns about obesity in that it is complex and difficult to manage, causing frustration for both the patients and practitioners (Ogden and Flanagan, 2008; Greener et al, 2010). The findings illustrate the frustrations from both patients’ and practitioners’ perspectives. This may suggest that where there is such complexity a ‘self-fulfilling prophecy’ may prevail (Sobal, 2004). That is, if both the public and practitioners feel weight management advice is ineffective, they may be less inclined to attempt to undertake or advise on weight management. Healthy eating policies today focus on weight management as a key method of helping to prevent chronic disease (Healthier Scotland, 2008; Public Health Agency, 2009; DH, 2011b). However, attention also needs to be paid to other aspects of diet in public health nutrition messages (Capacci et al, 2012). Perhaps this emphasis is reflected in the main themes running through the focus groups, which were related to weight management, despite other issues of healthy eating being important in managing chronic disease (Boyle et al, 2009; Diabetes UK, 2011; National Osteoporosis Society, 2011; British Lung Foundation, 2012; British Heart Foundation, 2013).

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LEARNING POINTS w Both patients and practitioners independently chose weight management to illustrate their experiences of dietary advice w Patients demonstrated a familiarity with the weight management discourse but often felt powerless to implement dietary advice w Practitioners in this study were less likely to think holistically about the causes of obesity and were ambivalent about the effectiveness of advising patients about weight management

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