Table 2.

Themes and Example Quotations

Theme/challenge	Example quotation (interview number, role, and type of practice follow quotation.)
Theme 1: Addressing obesity is as an essential part of primary care
	1. “It’s just part of my regular family medicine practice to counsel and treat obesity…obesity is related to many health conditions, and also to emotional, psychological issues that patients face how they feel about themselves as well as how their physical health is, so we need to address it.” #40, Physician in standard primary care practice
	2. “[In the past] I would say what every other doctor says—you need to lose weight and exercise more, and the people would say, ‘Yeah. I know.’ And they would come back next year, and they would be the same weight or heavier. So I mean I was 4 years and 3 months into a 5-year partnership buy-in when I basically decided that I didn’t want to keep practicing medicine this way, and I just left.” #29, Physician in obesity focused practice
	3. “We do a lot of preventative care because we want to provide answers for our patients, and weight loss is one of them.” #81, Physician in standard primary care practice
Theme 2: Due to several challenges, many clinicians opt out of specifically providing weight management in their practice
Challenge #1—I don’t know how to comprehensively tackle this problem!	4. “I still think that the amount of training that medical students and primary care residents are getting now is pretty skinny, and until something really happens about that—really embraced better, you’re still gonna have the problem of supporting it in the practice.” #64, RD in a family medicine residency training practice
	5. “I don’t have the training to give them what they really need—I mean I can start the conversation, sure, and I’ve had plenty of patients take what I’ve told them and run with it, and do really well for themselves, but most people they need a health coach; they need a dietitian.” #68, Physician in standard primary care practice
	6. “A lotta times I feel like they know what foods are healthy and how much they should be eating and everything, and so it’s more of a behavioral issue, I encourage them to seek out behavioral counseling through a therapist” #54, RD in standard primary care practice
	7. “Well, my take—I don’t find that they’re [medications] durable.I mean, you can’t keep people on these for their whole life.If they don’t learn lifestyle changes, whatever they’ve lost they’ll put right back on when you take ‘em off” #6, Physician in standard primary care practice
	8. “And so, again, that’s been a kind of a workflow challenge for the clinicians just to think about reviewing those behavioral health notes too—another piece of information to review either during the visit or in our pre-visit huddles that we do now too—it’s still a work in progress. We’re trying to figure out the right amount of time, who needs to be at the huddles, to have the greatest impact.” #63, Physician in standard primary care practice
Challenge #2—This is a complex, multifaceted problem	9. “I think we just have to recognize this is a lifelong, relapsing, chronic disease. There have to be treatments available through a lifetime, and when you look at the data of long-term weight maintenance it’s really poor…this is complicated, and it’s multi-factorial, and it’s difficult, and it isn’t about what you eat.” #22, Physician in obesity focused practice
	10. “Oh, that’s hard because everyone is so busy, and I feel like the nutrition’s pushed down the side. So, to make that more relevant I think what needs to happen is that a doctor has to take a chance on adding a dietitian to the team, and then hopefully seeing the improvements in patients when they do see you.” #30, RD working in standard primary care practice
	11. “We’re still learning about all the factors that sort of drive obesity. Our behavioral health people are helping us. We’ve got a little bit around history of trauma and other things that can relate to adult obesity, and so we’re sort of taking a deeper dive into not only helping people with their obesity but trying to get more into the person’s head and figure out what’s really driving their eating behaviors.” #63, Physician in standard primary care practice
	12. “It’s got to be a transformational process. You gotta do behavioral approaches. You gotta do physical activity. You gotta do lifestyle coaching, and counseling, and the whole kit and caboodle, so—and I guess I would just say that there’s no one treatment approach that’s perfect. It’s just individualizing treatment for the person.” #22, RD in standard primary care practice
Challenge #3—I simply don’t get paid enough to provide weight management compared to other services and it is a huge hassle to try	13. “Reimbursement’s real important. So it’s—you know, it’s an important thing, but, you know, it’s hard to get physicians to do it if they’re not getting paid.” #11, Physician in standard primary care practice
	14. “I believe the most frustrating part of this is some insurers, they pay for the visit if the BMI’s over 30, but now we do a good job and the BMI’s under 30, now they won’t pay for the visit anymore because they’re not obese. If we were managing hypertension, and then we got their blood pressure under control, we could still bill for hypertension.” #34, Physician in obesity focused practice
	15. “[Patients] are allowed a once a year a preventive visit and that’s the one time you can deal with something like that [obesity]. So, you have to list the physical first, and then you can list out the fact that you gave ‘em a BMI number, and talked to them about diet and exercise. So, the frustrating things is, is that you can’t really say that you treat obesity. Nobody does. We don’t get paid for that…maybe they ought to pay us for treating it.” #52, Physician in standard primary care practice
	16. “It’s not as straightforward as they [Medicare] made it to be. Like I read the 40–60 pages of how to bill and things of that nature with Medicare back in the day. And it’s not that straightforward because I would bill and they will come back saying, “Oh, it’s denied because you don’t have this code.” So it’s not 100% transparent in that way.” #1, Physician in obesity focused practice
Challenge #4—I am fighting an obesogenic American culture	17. “We reward bad behavior, right. I mean I’m sitting in my office looking at the common area across from my door, and it’s Friday, and people are bringing food to the office, and you can bet it’s not a vegetable tray, right?” #55, Practice manager, hybrid primary care/obesity practice
	18. “It is routine for us to admit you know patients into our ICUs just with obesity-related illness. You know, you go out to eat, you go to the mall, you go to Walmart—it’s everywhere, and the hospital’s no different. It is kind of normalized within some subcultures, within some families. It’s self-propagating. I mean, goodness, I’ve got, you know, a family will come in everybody is over 400 pounds, and how am I gonna break this cycle?” #59, Physician in standard primary care practice
Theme 3: Despite the challenges, many clinicians find treating obesity rewarding and satisfying
	19. And that’s the important thing is that they haven’t given up, and you can have set backs, then you can have some yo-yoing and, you know, up and down, but obviously what’s the best success, when somebody does lose a lot of weight, when they turn around their sugar, when they turn around their blood pressure. You know, those are the tremendous victories that we don’t get very often, but when you get them, it’s wonderful and exciting… #40, Physician in standard primary care practice
	20. Yeah. And it’s been fun, you know. It puts some fun back into practice [laughing]. It’s really good and people are so happy and thankful, and you know, it just gives so many people a new lease on life. #13, Physician in standard primary care practice
	21. “You get to celebrate stuff with them … and that gives you some of your job satisfaction back that’s being sucked outta ya every day with this other stuff that’s going on. Cause when you’re seeing results, they’re happy, you’re happy, you’re talking about things that really are impacting their life, and they’re happy.” #17, Physician in standard primary care practice
	22. It’s just so rewarding…she was the most bristly, porcupine-type patient. [I] worked with her and she lost 60 pounds, and then kind of lost track of her, and then on my desk was an invitation that in her church you could ask anybody on earth who’s changed your life to come to church with you that one day. And that invitation showed up on my desk—to come to the church service with her as a thank you for the biggest person who’s made the biggest change in her life, and you could have just blown me away with a feather. #79, Physician in standard primary care practice