People with obesity complications identified weight loss outcomes and effects on their obesity related complications and quality of life as major influencing factors in their choices. Their decisions were influenced by their beliefs and attitudes towards their HCP and the information, communication strategies, and recommendations provided about the need for this treatment. Participants explained that they received some information about medication availability through the media, but this did not influence their choice. Most information pertaining to pharmacotherapy came from their HCP, which highlights the value for improved health literacy. Their choices were influenced mainly by the perception of their health conditions, their health beliefs, and their relationship with their doctors which was deemed of paramount importance when choosing pharmacotherapy. Participants had concerns around side effects, availability of support, follow up, and taking the medication for life. Several participants addressed the issue of medication adherence. Beena et al. (2011) distinguished between medication adherence and compliance. Medication compliance means that the patient complies with the physician’s authority, while medication adherence refers to a collaboration between physician and patient in an effort to improve patient health [7]. Bissell emphasized how communication between HCPs and patients should be viewed as a possible way to combine the expertise of both to agree on mutual goals [10]. This concept of flexibility is where an understanding of patient and provider beliefs and preferences is important when deciding interventions [11]. Knowing and understanding what the patient wants to treat obesity in this way can prevent conflict [12].

A number of studies have taken different approaches to analysing patient with other chronic diseases and their preferences from systematic literature reviews to qualitative interviews. They all identified cost, side effects, knowledge, and the health benefit which is consistent with the themes found in this study. For example, Gomez-Peralta et al. (2021) conducted a quantitative study on patient preferences for pharmacological diabetes treatment conducting a questionnaire with 238 participants. They found the most important aspects for patients was health outcomes, adverse events, treatment characteristics, and treatment costs. They concluded that people with diabetes prefer treatments that reduced blood pressure and their HbA1c level [13]. Muhlbacher et al. (2014) conducted a literature review on patient preferences in treatment of diabetes mellitus: Thirteen studies were included in the analysis and they found that blood sugar control, side effects and long term complications as well as the mode of administration were the most patient relevant outcomes [14]. Xu X et al. (2022) conducted a systematic literature review on patient preferences, expectations and value for the management and treatment of hypertension. They identified that the side effects, cost and convenience were important factors for patients [15]. They also identified that patient’s preferred shared decision making on treatment options. In a qualitative study conducted by Neus Pages-Puigdemont et al. (2016) on patients’ perspective of medication adherence in chronic conditions, 36 participants were interviewed and they found that the participants health beliefs and perceptions of disease control impact adherence in chronic patients [8]. They also highlighted the importance of the patient-HCP relations and recommended further research to focus on shared decision making and more health education [8].

Patients’ voices and preferences have played an increasing role [5] and this has led to a stronger focus on shared decision making highlighting the importance of clear, concise communication, information and a collaborative relationship between the HCP and the patient [8]. This highlights the need to improve health literacy for patients, improve knowledge for HCPs, and increase support for those wishing this therapeutic approach. Further research is recommended on how people can access information around new pharmacotherapy options as well as the value of increasing access to this treatment pathway.

The limitations of the study include that the primary focus was on understanding the choices of patients between nutritional therapies, pharmacotherapies, and surgical therapies. This sub study to understand decision making of patients regarding pharmacotherapy was not the primary objective, albeit that the rich data allows novel insights. The sample size is relatively small, but in qualitative research, the sample size is not determined by a power calculation, but rather by the ‘theoretical sufficiency’ [16] of the data. This sufficiency is determined by the quality of the data collected—their richness, depth, diversity and complexity, what can be glossed as data or sampling adequacy – rather than the quantity of data collected [16,17,18]. Thus, based on the saturation which occurred in the emerging themes from this work, recruiting more patients would not have yielded additional themes. The patients that were recruited were not representative of the wider global population, but qualitative research is not extrapolatable because the data is only relevant to the patients studied within the qualitative study.

The strengths of the study include that the patients who were interviewed were unselected with regards to their enthusiasm for any obesity treatment. The initial launch for treatments which effectively addresses complications of obesity such as type 2 diabetes, including semaglutide and tirzepatide, has exceeded all expectations [5, 19,20,21]. This resulted in a shortage of medications and a prevailing view that most patients living with obesity want to be treated with medication. However, the estimates are that in late 2023, only 8% of patients with obesity were on pharmacotherapy. Thus, it is not possible to estimate at present if medications were available without any supply restrictions and how many people living with obesity would be receiving pharmacotherapy. As such, there may be a “ceiling” beyond which pharmacotherapy cannot easily grow. For example, if bariatric surgery is made freely available to the public with very few limitations for access, such as in Belgium or Luxembourg, fewer than 3% of the eligible population will select to have bariatric surgery. It is therefore important to understand what are the factors which would prevent a large majority of people living with obesity to consider pharmacotherapy for the treatment of the disease of obesity.