Abstract
Objectives:
To identify patient characteristics, health concerns, and barriers to care based on overweight or obesity.
Methods:
A 50-question anonymous survey was administered to patients. Data were compared by body mass index (BMI).
Results:
Among 3976 distributed surveys, 899 were returned and 682 were analyzed. Most respondents were women (60%), White (94%), and married/partnered (65%) and had some college education (80%). Younger and unmarried persons had higher BMI (P < .001). Concern for quality of life (P < .001) and importance of lifestyle changes (P = .006) increased with BMI, but confidence in making changes decreased as BMI increased (P < .001). Perceived good health decreased with increasing BMI (P < .001), whereas depression and other comorbid conditions increased. Self-esteem decreased and stigma increased with higher BMI (both P < .001). Weight discussions with clinicians (P < .001) and belief that clinicians should be involved in weight management (P = .002) increased with BMI, yet self-perception of being judged by clinicians also increased (P < .001). As BMI increased, delays in seeking health care increased (P < .001).
Conclusions:
This survey study highlights perceived health concerns and barriers to care among persons with overweight and obesity. With higher BMI, self-esteem decreased, and stigma, self-perception of poor health, perception of being judged by clinicians, and delay in seeking medical care increased.
Introduction
Obesity is defined by the World Health Organization as “abnormal or excessive fat accumulation that presents a risk to health” at a body mass index (BMI) of 30.0 or greater. 1 Obesity is now acknowledged as a chronic illness and is associated with an increased risk of the development of more than 200 medical comorbid conditions. 2 In addition, obesity can lead to depression and lower self-esteem, 3 and it is associated with increased risk of all-cause mortality 4 as well as increased health care spending. 5 Despite increased awareness of the effects of obesity, however, its prevalence in America is expected to increase to almost 49% by 2030. 6
Promoting weight management remains a challenge. Health care factors related to this challenge include clinician bias, unfavorable patient perceptions, and social determinants of health. Unfortunately, clinicians may see “obesity as an avoidable risk factor that impedes their ability to treat and prevent disease.” 7 This clinician bias may be underrecognized, even during early medical training. Phelan et al 8 reported that if medical students perceived negative attitudes toward patients with obesity as being normative, these attitudes were significantly associated with poorer patient-centered behaviors. In addition, many physicians do not feel they have adequate training to provide the recommended intensive counseling for medical treatment of obesity, which is continually evolving. 9
From the patient perspective, avoidance of or delay in seeking health services was 1 of 10 themes identified in a review of studies examining perceptions of weight bias and its impact on engagement with primary health care services. 10 Similarly, according to the 2020 Joint International Consensus Statement for Ending Stigma of Obesity, “fear of prejudice and internalized weight bias cause direct and indirect harm to patients with obesity, as they are less likely to seek and receive appropriate treatment for obesity or other conditions.” 11 Phelan et al 12 reported that persons with higher BMIs might avoid care or switch doctors because of stigmatizing experiences and poor communication with doctors, and the subsequent delays may lead to adverse health outcomes. Related to this is the possibility that weight stigma may be more harmful than actual overweight or obesity itself. On the basis of the Health and Retirement Study and the Midlife in the United States Study, Sutin et al 13 found that weight discrimination was associated with a 57% increased risk of dying. Only by receiving feedback from patients regarding their personal experiences, health concerns, and perceived barriers can health care be improved for patients with overweight and obesity.
There are gaps in the current literature regarding both the granularity of data—specifics of health concerns and barriers to care—and the need for more contemporary data. Therefore, the aim of the current study was to evaluate characteristics associated with different degrees of overweight and obesity, including patients’ perceptions of health concerns and barriers to care.
Methods
Survey Development
We adapted a survey previously created by the senior author (I.T.C.), which was given to all patients at check-in for a primary care medical appointment or upon admission to a hospital medical service, to better understand and obtain feedback on their prior perceived experiences and interactions with their health care professional (HCP) concerning weight issues. 14 This cross-sectional survey study consisted of 50 questions focusing on opportunities, practices, knowledge, confidence, attitudes, and beliefs around weight management. Several questions had branched logic, and a majority of the questions used a visual analog scale (VAS), which included responses such as “strongly agree,” “agree,” “neutral,” “disagree,” and “strongly disagree.”
The sections of the patient survey included the following categories of questions: (1) Health care experience.14 -18 (2) The validated Brief Stigmatizing Situations Inventory (SSI-B) 19 as it relates to patients’ health care experience. (3) Personal experience with weight management. (4) The patients’ self-esteem, as assessed with the validated Rosenberg Self-Esteem Scale (RSES)20 -23 and how this in turn influences patients’ perception of their health care experience. (5) Self-reported weight and general health history, which included validated measures of depression and quality of life. Depression was measured with the validated Patient Health Questionnaire-2,24,25 and quality of life was measured with the validated 1-item Linear Analog Scale Assessment-1. 26 (6) Lifestyle and interest in lifestyle changes. (7) Demographic characteristics, including self-described gender.
Study Population and Survey Administration
This survey study was determined exempt by our institutional review board. The anonymous paper survey was distributed to adult patients (≥18 years) at check-in for a scheduled medical visit in several outpatient primary care sites and 1 inpatient hospital medical service in a single academic health care center. Surveys were handed out from September 28, 2020, to August 31, 2022. Data entry closed on October 31, 2022. No compensation was offered for participation. All patients were given a packet containing a cover letter, which also served as the oral consent and included the option to participate in or decline completing the survey. The packet also contained the survey and a stamped addressed envelope to return the completed/declined survey. All surveys were returned to a central location, which organized and counted the returned surveys before sending them for electronic data entry using a REDCap database.27,28 Returned surveys lacking demographic data on age, gender, weight, or height were excluded. Respondents with a calculated BMI less than 20 also were excluded because they may have different physical and emotional concerns, barriers to care, and medical comorbid conditions.
Data Analysis
The data for the current study represent a convenience sample of patients seen for a scheduled medical visit or hospital admission in a single academic health care center in a 2-year period. The effective sample size was determined by the number of patients who completed the survey during the study period.
BMI (weight in kg divided by height in m2) was calculated for each patient from their provided information. A BMI of 20.0 to 24.9 was considered normal, 25.0 to 29.9 was overweight, 30.0 to 34.9 was class 1 obesity, 35.0 to 39.9 was class 2 obesity, and 40.0 or more was class 3 (severe) obesity. 29
For all analyses, the independent variable was BMI category. The dependent variables of specific interest included self-esteem, stigmatizing situations, delaying health care for weight-related concerns, and perceptions of weight-related interactions with HCPs. Self-esteem (RSES) and stigmatizing situations (SSI-B) were analyzed as continuous variables; questions related to delaying health care and perceptions of interactions with HCPs were analyzed as categorical variables.
In all cases, continuous variables were summarized using median (IQR) and compared across BMI categories with the Kruskal-Wallis test. Categorical variables were summarized using frequency counts and percentages and compared across BMI categories with the χ2 test or Cochran-Armitage trend test. Two-tailed, P values less than .05 were considered statistically significant. SAS statistical software v9.4 was used for analysis (SAS Institute Inc).
Results
Of 3976 surveys distributed to patients during the study period, 899 (22.6%) were returned; of these, 682 (75.9%) were included for analysis (Figure 1). Response rates were 20% from the community internal medicine practice (the local city and county), 11% from the general internal medicine practice (worldwide catchment area, excluding local city and county), 8% from the bariatric specialty service, and 38% from the hospital internal medicine practice.
Participant flow diagram. BMI indicates body mass index.
Patient demographics and lifestyle questions are summarized in Table 1. For the 682 participants, the median (IQR) age was 68 (57-76) years and 60% were female. Participant age differed significantly across BMI categories (P < .001); median (IQR) age was 70 (58-78) years for those in the normal BMI range, which decreased with increasing BMI to 58 (50-67) years in those with BMI ≥ 40. Marital status also differed significantly across BMI categories (P < .001), with the percentage of participants who were married decreasing with increasing BMI. Persons with higher levels of obesity were also significantly more concerned about their quality of life (P < .001) and they felt it was important to make lifestyle changes (P = .006). In addition, whereas there was no difference in motivation to make lifestyle changes across the BMI categories (P = .60), persons with higher levels of obesity were less confident in their ability to make lifestyle changes (P < .001).
Participant Characteristics. a
Abbreviations: BMI, body mass index; QOL, quality of life.
Values are No. of participants (%) or median (IQR).
χ2 test for categorical variables and Kruskal-Wallis test for continuous variables.
Scored on a scale from 0 (lowest) to 10 (highest). For all lifestyle questions, data were available for >94% of respondents.
Comorbid conditions and general health perceptions are provided in Table 2. The frequency of comorbid medical conditions increased significantly with increasing BMI for all conditions (all P < .01), with the exception of heart disease (P = .47) and peripheral vascular disease (P = .75). The percentage of participants rating their general health as fair or poor also increased with increasing BMI (P < .001).
Comorbid Conditions and General Health Perception. a
Abbreviations: BMI, body mass index; PHQ2, Patient Health Questionnaire-2.
Values are No. of participants (%).
Data were missing for <5% of the respondents. The percentages provided in the table are based on those with data available.
Characteristics were compared across BMI groups (normal BMI group [20.0-24.9] vs other BMI groups) with the Cochran-Armitage trend test for all characteristics except for “General health,” which was compared with the χ2 test.
Results of the RSES, Brief Stigmatizing Situations Inventory, and weight-related questions for delaying seeking health care are summarized in Table 3. Self-esteem and concerns about stigmatizing social situations differed significantly across BMI categories (both P < .001) and were significantly worse with higher levels of obesity. Importantly, the frequency of delaying seeking health care because of weight-related issues increased with higher BMI (P < .001). Patients with BMI ≥ 40 had the lowest self-esteem and the highest frequency of delaying health care because they (1) had gained weight, (2) had been told to lose weight but had not, (3) thought they would be weighed, (4) thought their clinician would discuss their weight, or (5) thought they would be asked to undress.
Self-Esteem, Stigmatizing Situations Inventory, and Weight-Related Reasons for Delaying Health Care. a
Abbreviations: BMI, body mass index; RSES, Rosenberg Self-Esteem Scale; SSI-B, Brief Stigmatizing Situations Inventory.
Values are median (IQR) or No. of participants (%).
Data were missing for 9% of respondents for the RSES, 7% of respondents for the SSI-B, and <5% of respondents for the 5 questions related to weight-related reasons for delaying seeking health care. In all cases, the summaries presented in the table are based on those with data available.
Kruskal-Wallis test for RSES and SSI-B; Cochran-Armitage trend test for weight-related reasons for delaying health care.
Ranges from 10 to 40.
Higher scores indicate increased frequency of stigmatizing experiences.
Patients’ perceptions of interactions with their HCPs are summarized in Table 4. Patients with higher levels of obesity were more likely to have discussed their weight as a health concern (P < .001), ranging from 38% of patients with overweight to 88% of those with BMI ≥40. Higher BMI was also associated with patients’ belief that their HCP should have a role in their weight management (P = .002). Likewise, patients with higher BMI stated their HCP currently has a role in their weight management (P < .001), but this represented a minority of patients (21% of those with overweight, increasing to 43% of those with BMI ≥ 40). Of concern, the percentage of patients who reported feeling judged because of their weight also increased with higher BMI (P < .001). However, even in the highest obesity category (BMI ≥ 40), the majority of patients (84%) did not feel this way, and most patients believed their HCP treated them with respect or as an equal regardless of BMI category.
Perceptions of Interactions With HCP. a
Abbreviations: BMI, body mass index; HCP, health care professional.
Data from Croghan et al 14 ; used with permission from Mayo Foundation of Medical Education Research.
Values are No. of participants (%).
Cochran-Armitage trend test. For the questions asking how frequently their HCP treated them with respect and how frequently their HCP treated them as an equal, the comparison is for the percentage responding “Always.”
There was no significant association between BMI and the perception that HCPs have the necessary knowledge and skills to help patients manage their weight (P = .68) or whether patients could ask their HCP for weight loss advice (P = .25). Although no association was observed between BMI and patient belief that HCPs are able to spend enough time to give good weight loss advice (P = .07), 26% to 32% of those with overweight or obesity did not believe HCPs could spend enough time.
Discussion
Our patient-focused survey aimed to evaluate characteristics associated with different degrees of overweight and obesity, including patients’ beliefs about their weight and their perceptions of health care. Three concerning findings from our survey are that patients with higher BMIs reported self-perception of feeling judged because of their weight, increased stigmatization, and delaying seeking appropriate medical care. Other notable findings include that patients with higher BMIs reported discussing their weight as a health concern with their HCP, and the majority of patients with overweight or obesity (90%-95%) indicated their HCP should have a role in their weight management. However, only 21% to 43% of patients with overweight or obesity self-reported their HCP as currently having a role in their weight management. This corroborates an earlier patient survey with patients across 5 diverse health care institutions. 14
Fortunately, most patients feel that their HCPs are knowledgeable about treating their overweight or obesity. However, 21% to 32% of patients did not believe their clinician is able to spend enough time with them to give good weight loss advice, regardless of their BMI. These findings were especially noteworthy during the pandemic, since in-person appointments were often restricted, thus limiting or preventing patients from seeing their HCPs and/or having adequate treatment and counseling time. Indeed, our study highlights that even during the health priority of the pandemic, people were still concerned about their weight, and according to the patients, many weight-management issues have not improved in recent years.
Many of our survey findings may reinforce clinician assumptions, including that higher levels of obesity are associated with increased depression, lower self-esteem, more comorbid conditions and multimorbidity, and self-perception of worse health.12,14,30 However, we found that regardless of degree of obesity (as measured by BMI), patients showed no difference in motivation to make a healthy lifestyle change. Although patients with higher levels of obesity were more concerned about their quality of life and recognized the importance of making lifestyle changes, they had less confidence they could make such changes and were lower on the ladder of contemplation to make changes. These offsetting attitudes may help explain why there was no difference in their motivation to make lifestyle changes.
Our results align with the Obesity Medicine Association’s Obesity Algorithm for treating patients with overweight and obesity, which emphasizes a focus to “eliminate provider bias and stigma, identify self-sabotage, develop strong support, address stress management, sleep optimization, [and] other psychological support as needed.” 31
Several limitations of our study deserve mention. BMI, our method of categorizing patients, is a screening tool and does not diagnose body adiposity or health, 32 and it may not correspond to the same degree of excess adiposity in different persons. In addition, relying solely on BMI may underestimate or overestimate health risks among certain racial groups. 33 Also, because the survey was anonymous, we could not link the returned surveys to patients’ electronic health records; therefore, self-reported height and weight could not be confirmed. Furthermore, 94% of our respondents were non-Hispanic White, and the survey was conducted at a single center, although at varied locations/divisions/services. Accordingly, our findings may not be generalizable to more-diverse patient populations. Also, the majority of our survey respondents were from the inpatient service, which also may affect generalizability. We acknowledge the low survey response rate of 22.6%. Possible explanations for the low response rate include the length of the survey, no monetary compensation for participants, and that we collected data during the COVID-19 pandemic when outpatient appointments were limited. As a result, our findings are at risk for possible nonresponse bias, 34 although the large sample size provided adequate power to allow us to report significant findings. Of note, results related to the National Survey of Student Engagement indicated that data estimates remained reliable even with a 5% to 10% response rate if the sample size was at least 500; this adds support to the validity of our results. 35 Finally, our survey used a cross-sectional sample, so we can only report findings and associations but cannot prove causation.
The main strength of our study is that it reminds HCPs that what patients perceive or hear during the encounter may be more important than what is actually communicated to them. And, although it is reassuring that respondents believed their clinicians treated them with respect and as equals, it is discouraging and unacceptable that some patients still felt judged because of their weight and that some patients reported delaying medical care.
This study was unique for several reasons. First, it was more comprehensive in scope than prior similar surveys.10 -12,17,36 Our 50-question survey included a wide range of questions, which allowed us to better analyze multiple patient domains, including health and HCP concerns, issues with stigma, and insights into motivation to make healthy lifestyle changes. Second, we enrolled participants at the time of health care encounters, both outpatient and inpatient. Keeping an outpatient appointment may be indicative of a patient having interest in their own health, whereas being hospitalized might allow for a “teachable moment,” especially if patients are hospitalized related to an acute complication of their overweight or obesity. Additionally, being given a survey during an HCP encounter might “prime” patients to more honestly reflect on their weight and health issues, with perhaps more accurate answers than if the survey were administered in nonclinical settings. In contrast, other obesity-related surveys have primarily relied on community recruitment.10 -12,17,36 Third, data collection occurred during the COVID-19 pandemic, which may have further raised awareness of personal health concerns and vulnerability related to overweight and obesity. 37
Our study findings have relevant practice implications. We believe our results support several actionable items for clinicians that may help advance care among patients with overweight and obesity. We recommend that HCPs continually strive to make their practices inviting to patients with overweight and obesity by dedicating time to listen to and affirm their concerns, avoiding bias, promoting and maintaining a compassionate and nonjudgmental clinic environment, and ensuring that staff remain sensitive to and respectful of patient needs and concerns. HCPs and clinic staff should empower patients to speak out in stigmatizing situations to help them attain high-quality health care. 38 HCPs should strive to keep up with the latest literature or attend continuing medical education courses because the field of obesity medicine is changing rapidly. HCPs should also make available the most current educational resources related to weight management for clinic staff and patients, since confidence in their HCP’s skill set may enhance patient engagement. HCPs should initiate and promote supportive discussions on the importance of healthy lifestyle changes while acknowledging difficulties in doing so. Minimal intervention strategies such as the 5 A’s (ask, assess, advise, agree, and assist) 39 can guide the process of counseling a patient about lifestyle behavioral changes. HCPs should inquire about symptoms of depression and low self-esteem associated with obesity and empathetically offer support and discuss treatment options, including cognitive behavior therapy, if needed. Finally, HCPs should be attuned to possible comorbid conditions, which may be asymptomatic, and offer appropriate screening, such as for diabetes, fatty liver, or obstructive sleep apnea.
Conclusions
Our study highlights health concerns and perceived barriers to care in persons with overweight and obesity. Notably, self-esteem decreased and stigma increased with higher BMI, as did self-perception of being judged by HCPs and delaying seeking medical care. HCPs should be aware of and minimize stigmas associated with overweight and obesity, which may increase the risk of worse health outcomes. Clinicians may need additional training and resources for weight management, and they most likely need extra time during patient encounters. Ultimately, HCPs must remain nonjudgmental to help their patients gain the confidence they need to make lifestyle changes and treatment decisions as they navigate the challenges of weight loss. Future research should assess ways to integrate actionable items into clinicians’ already-busy practices.
Footnotes
Acknowledgements
We thank the Mayo Clinic Survey Research Center for the formatting and printing of the survey packets as well as the organization of all returned surveys and the Department of Medicine Research Hub for statistical support. We also thank Katie A. Cruz, Kyung-Min Shin, PhD, Jennifer M. Manggaard, CCRP, and Marybeth Floersch for assisting in the distribution and data entry. We would also like to sincerely thank the Scientific Publications staff at Mayo Clinic, who provided editorial consultation, proofreading, and administrative and clerical support. The authors have authorized Scientific Publications to submit the manuscript on their behalf, and the authors have approved all statements and declarations. Finally, a special thanks to all the participants who took the time to complete this survey. Without their participation, this study would not have been possible.
Author Contributions
All authors participated in the study concept and design, analysis, and interpretation of data, drafting and revising the paper, and have seen and approved the final version of the manuscript.
Declaration of Conflicting Interests
The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: J.O.E. serves on a scientific advisory board for Applied Aerosol Technologies and serves as a consultant to Exact Sciences and K Health, with reimbursement paid to Mayo Clinic. M.S.M. has research grants from Fresenius Kabi, Nestle, Realfood Blends, and VectivBio, and he is a consultant for NorthSea. S.L.B. serves on a scientific advisory board for CorMedix. All other authors have nothing to declare.
All authors declare no support from any organization for the submitted work; no financial relationships with any organizations that might have an interest in the submitted work in the previous 3 years; and no other relationships or activities that could appear to have influenced the submitted work.
Funding
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This study was supported in part by Mayo Clinic General Internal Medicine. The data entry system used was REDCap, supported in part by the Center for Clinical and Translational Science Award (UL1 TR000135) from the National Center for Advancing Translational Sciences (NCATS).
Ethical Approval Statement
In accordance with the Declaration of Helsinki, this study (#20-000526) was reviewed by expedited review procedures and was determined to be exempt from the requirements for institutional review board approval (45 CFR 46.104d, Category 2). During the study, all substantial changes to study design and procedures were appropriately filed for review, and exemption status was maintained throughout the study.
Consent to Participate
Protocol-approved passive consent was obtained from all study participants prior to study initiation.
Consent for Publication From Identifiable Patient
Not applicable.
Data Availability Statement
All data supporting the study findings are contained within this manuscript.