Table 2:

Factors influencing the formation and implementation of PCP plans for severely obese patients and representative quotes

Factors influencing formation of care plans
1. Patient acceptance of treatment plan	- “If you never want to see them again, you know what you say to them? ‘You’re morbidly obese and you really need to lose 25 pounds before I see you next time’.”
2. Availability of nurse educators, support staff, and educational materials	- “If I know that we’re already short on nursing staff, the last thing I want to do is add to their plate. You need to call this person every week, and you need to do blood pressure checks and weight checks, and I can’t physically do that to our staff at the moment.” - “Because, I know I’ve got a great one-page hand-out, front and back, that says, ‘Here’s a list of foods, all of which you’re familiar with. Pick the list from top to bottom. The bottom ones are always the better choices.’ I could easily, probably, spend two minutes on that, and it seems to be a fairly high-yield sort of improvement for many of these things.”
3. Considering the severity of obesity and comorbidities	- “There are people with BMIs of 32 that don’t have arthritis and diabetes, and they’re active, and they’re firefighters and, you know, maybe it’s genetics or build or whatever... I have a real hard time [critiquing] them because they’re over insurance companies’ standards for weight. They’re maybe the healthy overweight, per se, or they’re big muscular builds or whatever. So, that’s why I let some people get away without as much lecturing as others. But usually, I guess my line seems to be a BMI of 40.” - “If I haven’t looked at a BMI at the beginning of an encounter and then catching it at the end, and being like, ‘Oh, we should’ve talked about that and that wasn’t even at the top of my [list].’ I wouldn’t have known if I hadn’t seen the [BMI], and I think that’s my own normalization [because] so many of our patients are obese.”
Challenges to implementing care plans
1A. Lower socioeconomic status (patient level)	- “That single parent, sometimes they’re just, they’re strapped, they’re exhausted, they’ve worked all day, they go back to their three kids. It’s faster for them to hit the dollar menu at McDonald’s than to prepare a healthy meal. And she can feed herself and her three kids cheaper off the dollar menu than she really can prepare a healthy meal for four.”
1B. Eating as an addiction (patient level)	- “If certain types of foods were illegal, would it be all that much different from illicit substances? Probably not. A lot of people are addicted to certain types of calories.” - “When I talk to patients, I liken it to other addictions, like tobacco or drugs. You know, except it’s calories. You have to change who you hang out with, where you go…”
1C. Having prior weight loss failures (patient level)	- “Most of the morbidly obese patients we see have, at least once in their adult life, tried to lose weight or tried to manage their weight. Prior failures, I think, for a lot of my morbidly obese patients,…is a big barrier to them feeling like they could be successful if they embarked again on an attempt to lose weight.”
1D. Being in denial/making excuses (patient level)	- “If you talk to him, he swears he’s under 2,000 calories a day. You talk to his wife, and she says he’s eating bags of potato chips and boxes of food and, you know, a whole chicken at a time.”
1E. Limited physical mobility (patient level)	- “It’s hard to exercise when your [BMI is] 46. You’re just creaky. It’s hard to get moving and probably takes a lot of energy expended to actually move. But I find with these morbidly obese patients, it’s very hard to find some kind of aerobic exercise that they can actually do.”
2. Feeling ineffective in helping patients lose weight (practitioner level)	- “I have a panel of 1,500 patients at this point. I can think of one that has successfully lost fifty, sixty pounds. It was similar to this patient. But that’s one out of probably a thousand morbidly obese patients.” - “If it is a case like his wife made him come in, he’s probably not going to be too interested in making a whole lot of changes in all these things. And that impacts how much I’m going to bang my head against the wall, as well as what I’m going to kind of expect.”
3A. Poor reimbursement for services (system level)	- “I’ve had some roadblocks, where people are obese or morbidly obese and I’ve tried to refer them for dietary counseling, and [we were] denied because whatever insurance they had, they could get dietary counseling for diabetes only, not for obesity.”
3B. Culture promoting obesity (system level)	- “In America, we don’t eat because we’re hungry. We eat for comfort. We eat for pleasure. We eat for socializing.”