Primary Care Providers Perspectives of GLP-1 Receptor Agonists to Manage Recurrent Weight Gain after Metabolic Bariatric Surgery – a Qualitative Study

For this qualitative study, we employed purposive and snowball sampling methods [19] to recruit General Practitioners, Resident Physicians, Nurse Practitioners, Physician Assistants and District Nurses/Registered Nurses employed in primary care settings in the United States and Sweden between September 2024 and March 2025. We used our professional networks for recruitment, also the study participants could suggest new providers they knew could contribute with valuable information.

Eligible participants were those with experience in providing healthcare services in primary care to adult patients who had previously undergone MBS. A total of 56 PCPs were invited to participate in this study. Of these, twelve (n = 12) did not respond, six (n = 6) declined due to time constraints, limited interaction with post-MBS patients, or PCP perceived lack of representativeness of primary care. Among those who did not respond or declined were all PCPs represented, comprising eight (n = 8) men and ten (n = 10) women. PCPs received both oral and written information about the study and provided informed consent. Participation was voluntary, and no incentives were offered.

We employed a qualitative design and conducted virtual interviews once with each PCP. Interviews were conducted in Sweden, using Swedish language, by the first author a registered dietitian (LT) and in the US, using English language, by the senior author, a clinical psychologist (AMK), both within specialty obesity care practices. We utilized a pilot-tested semi-structured interview guide that focused on post-MBS care in primary care and recurrent weight gain after MBS. The questions were designed to be open-ended (e.g., Tell me about your experience of treating patients who have experienced recurrent weight gain after MBS), allowing PCPs to express their perspectives and experiences freely. Follow-up probing questions were strategically employed to encourage PCPs to explore their reflections on the topic more deeply.

On average, the audio-recorded interviews lasted 39 min, with a range of 21–101 min. Transcriptions were performed simultaneously using an Artificial Intelligence (AI) generated function in Zoom© or Microsoft Teams©. The transcripts were carefully cross verified with the original audio to ensure accuracy. The validation process was conducted by the first and last author, who carefully manually reviewed the audio recordings with transcriptions multiple times to identify and correct any errors or inaccuracies introduced by the AI.

In this qualitative study, we aimed to collect rich and relevant data with various experiences. Therefore, the decision regarding the number of participants was guided by the depth and richness of the data needed to address our research aims, rather than by a predefined point of data saturation, consistent with Braun and Clarke’s Reflexive Thematic Analysis principles [20]. We kept the original language (Swedish/English) during the initial steps of the analysis to preserve the nuances of language. However, codes, themes and selected quotes were translated to English by bilingual Swedish researchers, and the English wording was verified by native English-speaking researchers in this project. All interviews were conducted confidentially, and all data files were de-identified to maintain participant confidentiality. If any participant gave especially unique information, the results were appropriately pseudonymized.

We manually analyzed the interview data transcripts with a step-by-step process utilizing inductive reflexive thematic analysis following the framework developed by Braun and Clarke [20]. The objective was to generate themes and subthemes that meaningfully captured the depth and complexity of PCPs’ perspectives. We specifically selected narratives from the collected data corpus that pertained to the experiences of primary care providers with GLP-1RAs in the context of recurrent weight gain following MBS. The data extracts were coded and systematically organized into sub-themes and one overarching theme, effectively encapsulating the essence of the participants’ narratives. The process of thematization involved iterative refinement and active collaboration within the research team.

Within an international and interdisciplinary team comprising experts in clinical obesity care, primary care, endocrinology, psychology, nutrition, epidemiology, public health, and weight stigma, we ensured reflexivity through regular meetings. Those meetings facilitated open discussions aimed to minimizing individual biases and preconceptions, particularly those of the first and last authors. The first (LT), second (KM), and last authors (AMK) engaged in collaborative dialogues to develop initial codes and themes, thereby enhancing reflexivity and deepening interpretative scientific rigor. All co-authors contributed to reviewing and refining the themes and sub-themes, offering critical insights that enriched the analytical process.

In total, thirty-eight (n = 16 from the US and n = 22 from Sweden) PCPs were included as participants. Their experiences in following patients after MBS varied substantially, from meeting these patients only occasionally to providing routine follow-up visits annually. See Table 1 for participant characteristics. Not all demographic data was collected from the US providers, yielding missing demographic data, which is highlighted in Table 1.

During the reflexive thematic analysis one primary theme “ GLP-1RAs: Navigating between breakthrough and uncertainty” and six sub-themes “Bridging gaps in post-MBS care,” Tsunami of GLP-1RA requests,” “Systematic barriers to accessing GLP-1RA treatment,” “Limited knowledge and experience,” “Not a standalone solution” and “GLP-1RA transform the future for MBS” were generated. Representative quotes are presented in Tables 2, 3, and 4 for each sub-theme.

The primary theme was a common thread throughout the data and captured the novel circumstances that the PCPs faced when considering use of GLP-1RAs in the treatment of obesity and in the context of recurrent weight gain after MBS. They expressed a positive attitude towards GLP-1RAs, noting their effectiveness and facilitation of discussions regarding weight with patients. However, there were concerns about whether primary care resources were adequate for handling prescription requests, and there was a perception that patients viewed GLP-1RAs as a miraculous solution which sometimes contrasted with PCPs’ clinical experiences. Additionally, PCPs sought guidelines on the proper use and safety of GLP-1RAs for patients after MBS. GLP-1RAs were considered to alter both patients’ treatment preferences and their own referral patterns to MBS.

Bridging gaps in post-MBS care, see Table 2 for representative quotes.

Primary care providers (PCPs) found it challenging to address recurrent weight gain after MBS when the only treatment tool available was individual-level, difficult to modify, health-related behavior change (e.g., dietary changes, physical activity). However, the advent of GLP-1RAs changed PCPs’ perceptions, offering a new, exciting, and potentially more effective treatment option, especially for patients who had undergone MBS several years ago with re-emerging comorbidities. PCPs described that GLP-1RAs offered renewed optimism for patients’ weight management. GLP-1RAs were considered as a tool for treating recurrent weight gain and as a complement to MBS for further weight reduction. GLP-1RAs were perceived as life-changing for patients which made prescribing them rewarding. Additionally, GLP-1RAs were perceived to enhance awareness and interest in obesity treatment. GLP-1RAs were suggested to be integrated as a routine component, as early as possible, in follow-up care after MBS, as PCPs had observed improvements in patients’ quality of life and health. Sometimes PCPs reported being unaware of patients’ previous MBS history due to the lack of documentation in patient records or that it was not disclosed during the consultations. PCPs reported increased confidence in addressing weight and obesity with patients due to GLP-1RAs, media coverage, and training availability. In addition, PCPs reported feeling more empowered in weight-related conversations when offering more than just advice on health-related behaviors.

Tsunami of GLP-1RA requests, see Table 2. for representative quotes.

PCPs in the US and in Sweden described experiencing an overwhelming demand for GLP-1RAs among patients with overweight and obesity, as well as patients after MBS. They perceived GLP-1RAs as “trendy” and noted that patients often saw them as a “magical pill.” They found that patients focused mainly on obtaining prescriptions rather than comprehensive obesity treatment. Generally, PCPs perceived their patients as well-informed and aware of specific GLP-1RAs they wanted. Media coverage was seen as driving increased demand. PCPs experienced that GLP-1RAs required significant resources for initiation and follow-up. They indicated that the deluge of requests was stressful and burdensome, as it resulted in a constant stream of patients needing support (e.g., with injection techniques, with various GLP-1RA dosages, pens, and syringes, and with managing side effects).

Systematic barriers to accessing GLP-1RA treatment, see Table 3 for representative quotes.

PCPs experienced multiple obstacles preventing patients from initiating or maintaining GLP-1RA treatment. Their main concern was surrounding the financial burden for patients, particularly a lack of insurance coverage or financial subsidies, negatively affecting care continuity. PCPs noted that patients’ financial resources directly influenced their access to treatment. In Sweden, patients must bear full costs of medication, with obtaining national insurance support deemed nearly impossible. In the US, PCPs expressed concerns about inequitable access to the medications arising from lack of insurance coverage or coverage limits. PCPs expressed interest in subsidies for GLP-1RA treatment, however, they also worried about the societal financial burden of universal coverage. Patients often found insurance issues frustrating, especially when reaching benefit limits according to PCPs.

Although the availability of GLP-1RAs had increased over the past year, PCPs also expressed concerns about access to GLP-1RAs for patients who have conditions for which the medications are covered or subsidized (e.g., those with type 2 diabetes), while remaining optimistic that availability and prices would improve over time. In addition, PCPs, especially those in Sweden, felt that the lack of guidelines for the use of GLP-1RAs in post-MBS care to be problematic, and that they were sometimes limited in offering these new treatments due to regional restrictions. They expressed concern that their patients could obtain prescriptions for GLP-1RAs through various physician-led digital platforms (mobile applications or web-based services). This could result in PCPs being unaware of their patients’ GLP-1RA treatment, thereby creating uncertainty regarding follow-up, patient safety, and increasing patients’ out-of-pocket costs. They believed that this approach was not beneficial to the patients or society.

Limited knowledge and experience, see Table 3 for representative quotes.

PCPs reported variability in prescribing and managing GLP-1RAs after MBS care. While some felt confident, others lacked experience. They perceived a need for more research and clinical experience and expressed interest in using GLP-1RAs in primary care, while noting variability in clinical practices. Given these therapies’ novelty, particularly post-MBS, clear guidelines were needed. PCPs’ GLP-1RA prescribing practices for post-MBS patients aligned with their approach to treating patients without previous MBS. PCPs’ considerations focused on long-term efficacy and safety, particularly regarding nutrition and body composition.

In addition, PCPs expressed concerns about patients struggling with appetite regulation despite GLP-1RA treatment. Management of side effects and nutritional guidance were highlighted as risks to patients after MBS to consider. PCPs found it challenging when patients experienced recurrent weight gain despite GLP-1RA use or when treatment was ineffective. Recurrent weight gain after discontinuing GLP-1RAs and ongoing eating difficulties were also described. The PCPs noted that body image and mental health issues often persisted during treatment.

Not a standalone solution, see Table 4 for representative quotes.

PCPs emphasized that GLP-1RAs after MBS should be integrated with behavioral interventions and medical nutrition therapy for sustainable outcomes, stressing the need for support in health-related behavior changes for optimal long-term results. Some referred patients to dietitians and encouraged physical activity, emphasizing individualized care to sustain patient motivation. However, comprehensive support was not always feasible in all settings, and they found it challenging to advise additional treatment and meet patient expectations if they only demanded GLP-1RA prescriptions. The PCPs expressed that they were convinced that additional support could help patients set realistic goals, improve satisfaction, and enhance adherence.

GLP-1RA transform the future for MBS, see Table 4 for representative quotes.

The introduction of GLP-1RAs had influenced how PCPs viewed MBS. They observed that patients in both the US and Sweden were now more likely to explore GLP-1RAs instead of seeking referrals for MBS or considering MBS options abroad. However, PCPs reported that patients did not always seem interested either in MBS or GLP-1RAs, asking PCPs to adjust their approach to “meet patients there where they are.”

The PCPs perceived the future of MBS in the treatment of obesity as uncertain with the emergence and efficacy of GLP-1RAs. They reported a shift in their attitudes towards referring patients for MBS; preferring to initiate GLP-1RAs before considering referrals, whereas others expressed reservations about making such referrals. PCPs emphasized that some patients would need MBS based on medical history and health goals. For instance, those who cannot afford GLP-1RAs, do not respond to treatments, or have body mass index over 45–50 kg/m² could be recommended MBS. PCPs also suggested MBS could be more cost-effective long-term compared to continuous GLP-1RA use. Additionally, GLP-1RAs were viewed as a potential step towards surgery, particularly for patients who achieve weight loss with medication and want to maintain these improvements.

While previous work has focused on PCP perspectives on weight-loss medications broadly [17, 18], the current study zeroes in on provider perspectives specifically after MBS, an important contribution to the literature. Given that GLP-1RAs represent a novel treatment option for recurrent weight gain after MBS on a global scale, the perceptions and experiences vary among PCPs. However, the main strength of this qualitative study lies in its international scope, which enhances the transferability to different contexts. Overall, PCPs were excited about GLP-1RAs’ potential (breakthrough) but were grappling with knowledge gaps, system hurdles, underlying stigma, and questions about how these drugs fit with surgery (uncertainty).

Despite the strengths of the current international study with a large sample size, some limitations must be acknowledged. Qualitative research prioritizes depth over breadth; therefore, while the findings offer valuable insights, they may not reflect all PCPs. Our inclusion criteria required participants to have some experience with MBS, ensuring perspectives grounded in relevant clinical experience but excluding PCPs with no exposure to this patient population. Nonetheless, participants represented a range of familiarity with MBS and GLP-1RA prescribing, reflecting the variability typical of “real-world” primary care settings.

We actively strived for a variation of perspectives and experiences in our study. However, a limitation is that the most participants were women. Future studies could specifically focus on to explore male PCPs perspective. It is a strength for our results that we could include healthcare professionals with different experiences. District Nurses and Registered Nurses were more actively engaged in supporting patients with changes of health-related behaviors, in contrary General Practitioners and Nurse Practitioners had more of a role of managing patients’ treatment and prescribing GLP-1RAs.

This study captured PCPs attitudes at one time point. However, given the evolving landscape of GLP-1RAs, these perspectives may change as new guidelines emerge, prevalence increases, or access, coverage, and cost evolve. Recruitment used purposive and snowball sampling, appropriate for hard-to-reach populations, but potentially introducing selection bias. Participants who volunteered may not represent the broader PCP population, as those with specific interests may have been more willing to participate in the study. This limitation affects the interpretation of the results. The participants showed diverse experiences and perspectives. Despite interviewers’ efforts to encourage openness in participant responses, some viewpoints may be underrepresented, especially given the novelty surrounding GLP-1RAs. Furthermore, PCPs may have provided socially acceptable answers rather than their true experiences due to social desirability bias.

The interviewers aimed to collect rich, comprehensive, and in-depth data, however the duration of the interviews varied. While the length of an interview does not inherently determine its quality, shorter interviews may lack completeness, and longer interviews may not necessarily guarantee the desired depth [19]. To mitigate potential bias during data collection, we employed only two interviewers, one in each country, to ensure consistent interview quality irrespective of time constraints. Researcher reflexivity was maintained through interdisciplinary discussions throughout the research process. Our professional background as obesity researchers and clinicians may have both limited and strengthened our interpretation of interview data. The reflexivity efforts aimed to increase awareness of this influence.

Although including participants from both Sweden and the United States strengthens the study by capturing perspectives across two distinct healthcare systems, the applicability of these findings to other contexts may be limited. Differences in healthcare organization, cultural attitudes toward obesity, and access to treatment may influence the manifestation of these themes in other regions. Future research, including providers from additional countries and settings, particularly low- and middle-income contexts, would help clarify the global relevance of these findings.

By understanding PCPs perspectives and generating themes presented here, several recommendations for action reveal. Our findings suggest an urgent need for official guidelines on post-MBS use of GLP-1RAs with PCPs included in developing these given their frequent role in providing long-term post-operative care. As a start, international guidelines are emerging e.g., IFSO recommends considering GLP-1RAs before revision MBS in cases of recurrent weight gain [10]. However, PCPs in our study were largely unaware of such guidance, indicating a gap between specialist consensus and primary care practice.

Clear guidelines and recommendations on when to use GLP-1RAs before and after MBS would be helpful for PCPs to do shared-decision making with their patients and to provide the most safe and effective treatment approaches to treat recurrent weight gain. PCPs expressed a lack of clarity about use of GLP-1RAs after MBS, and this was complicated by not always knowing a patient’s full medical history including whether they had even had MBS in the past. Concerns regarding nutritional challenges, effects on body composition, and MBS-related side effects were emphasized by PCPs. These aspects are also highlighted by IFSO in a Delphi Consensus Position Statement, advising GLP-1RA treatment before revisional surgery [10].

The identified themes brought up a few additional considerations that warrant further research. For instance, PCPs commented on patients wanting medications as a “quick fix,” which may reflect underlying weight bias, as it is consistent with findings that GLP-1RA users are stigmatized for “taking the easy way out” [25]. However, they also noted that bringing up GLP-1RAs has made it easier to have weight-related conversations with patients. Thus, it is not immediately clear whether PCPs having more conversations about GLP-1RAs would increase or decrease patients’ experiences of stigma. On the one hand, having additional treatment options for post-MBS patients experiencing recurrent weight gain may help PCPs have more positive, supportive conversations with their patients, but on the other hand, if PCPs continue to view patients seeking GLP-1RAs as wanting “a magical pill,” those conversations may still be laden with stigma. Future research should examine the role that GLP-1RAs play in weight-related communication and stigma for patients post-MBS. At the systems level, it will be important to examine how lack of insurance coverage and the exorbitant cost of GLP-1RA medications makes obtaining this treatment so difficult for patients, particularly because those financial barriers may affect patients’ choice to use GLP-1RAs pre- or post-MBS [24].

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. The Swedish Ethical Review Authority (registration number 2024-07238-01) and The Mayo Clinic Institutional Review Board (registration number 24-007666) approved the study.

Informed consent was obtained from all individual participants included in the study.

The authors declare no competing interests.

Data availitibility is not possible due human research participants may present a risk of reidentification if shared openly.