Weight-Biased Health Professionals and the Effects on Overweight Patients

Abstract

A significant number of Americans are obese. Weight bias and negative attitudes have been documented among medical professionals, and these may cause obese patients to avoid seeking health care, leading to undiagnosed pathology. Some physicians lack adequate resources and patient counseling skills when addressing patient weight management. This may lead to continued weight problems and associated complications for the patient. Many physicians do not address patient obesity with urgency and determination, even though most physicians consider obesity a widespread, problematic disease. The purpose of this literature review is to assess weight discrimination and negative attitudes among health professionals and how those attitudes affect quality of care for overweight patients. Through these generalizations, sonographers can become aware of their own biases, which may lead to poor patient care.

In 2014, the National Health and Nutrition Examination Survey estimated that 35% of adults (body mass index [BMI] >30) and 17% of youth (BMI above 95th percentile of age- and sex-specific charts) in the United States were clinically obese. ¹ As obesity continues to increase, sonographers and other medical professionals must be devoted to giving unbiased care with confidence and positive attitudes. Current literature suggests that a large percentage of medical professionals are weight biased or have negative attitudes when treating overweight or obese patients.^2–11 Some physicians simply lack adequate resources and training to provide adequate care for this group of patients. This literature review examines the negative attitudes of medical professionals toward overweight patients, leading to inadequate patient counseling, treatment, and other consequences. By evaluating research focused on this topic, it is hoped that sonographers may be made more aware of the potential for weight bias when interacting with patients and how that can affect patient treatment.

Provider Perspectives

Provider Perspectives of Causes for Obesity

Harvey and Hill ² surveyed 255 physicians, who listed their five top-rated causative factors for becoming overweight as physical inactivity, food addiction, personality, depression leading to overeating, and a lack of willpower. Less controllable factors such as metabolic defects, fat cell defects, and age were rated lowest as causes for becoming overweight. ² Thuan and Avignon ³ reported on 607 physicians, who noted poor compliance or lack of willpower in most of their patients. Overall, obese patients were considered responsible for recognizing their weight as a problem and doing something about the situation.^2,3

Provider Attitudes Toward Obese Patients

Sabin et al ⁴ studied 2384 physicians, who showed strong obesity bias regardless of whether the physicians themselves were underweight, normal weight, or overweight. Medical students have shown similar biased attitudes, with results indicating higher negativity when interacting with the obese patient versus the nonobese patient.^4,5 Physicians described obese patients as having unrealistic goals; 66% of 607 physicians believed few patients could lose weight and maintain that loss. ³ Other caregivers have shown similar attitudes; 60% of nurses polled believed obese patients were lazier than other patients, and around 50% believed obese patients were not motivated to make a lifestyle change. ⁶ While no specific studies addressing sonographers’ attitudes have been published, it is likely that the findings of such a study would mirror those already mentioned. In general, overweight people were believed to have less self-esteem, sexual attractiveness, and health compared with people who were not overweight. ² There were negative attitudes identified, as these medical professionals believed it to be the overweight individuals’ responsibility not only to recognize that there is a problem and that it is a risk to their health but also to identify the cause of the obesity and ultimately find motivation to lose the weight. ²

The association between specific words and overweight individuals can identify possible weight bias among medical professionals. The Implicit Associations Test (IAT) and a self-report questionnaire evaluate obesity biases. When using this test, research results from practicing clinicians and their students suggested that health professionals associate negative attributes with obese patients more often than positive attributes. The words bad, lazy, stupid, and worthless were all chosen more often than good, motivated, smart, and valuable when describing an obese individual.^5,7

Teachman and Brownell, ⁸ as well as Puhl et al, ⁹ focused their research on attitudes of eating disorder specialists. Fifty-six percent of participating eating disorder specialists stated they have experienced other medical professionals making negative comments about obese people. ⁹ Fewer specialists were biased than were general providers, yet many specialists still endorsed an antifat attitude, suggesting that thin people were more motivated than obese people. ⁸

Provider Attitudes Toward Self

Physicians themselves expressed frustration and doubt when treating obese patients. Close to half claimed they were not professionally well prepared to treat excessively overweight patients, ³ and only 50% found that counseling patients through the weight loss process was rewarding. ³ In several studies, most participants empathized with the obese patients but still perceived them as lazy and unattractive.^6,10,11 Researchers have not shown definitively why negative attitudes develop, but there are major concerns that quality of patient care could be compromised when negative attitudes develop and a lack of knowledge in how best to care for the patient is prevalent.

Obese Patient Attitudes

Evans ¹² surveyed 372 prior obese patients who lost weight regarding how they perceived weight loss advice from their physicians. Twenty-two percent reported receiving positive advice, which included referrals to eating specialists, dietitians, weight loss groups, or prescription of medication. Forty-three percent reported receiving vague advice to “eat less” and “lose weight.” ¹² Overweight women have stated feelings of dismissal and struggling to fit in when having health care procedures. ¹³ Their struggles to fit in related to undersized hospital equipment and their dismissal related to embarrassing conversations and interactions with their caregivers. Patients were asked to rank how they were treated by providers prior to losing weight compared with after losing weight. Forty-five percent felt they were treated disrespectfully by providers prior to losing weight versus 35% who still felt that way after losing weight. ¹⁴ This may imply that some patients feel disrespected regardless of their weight or that negative attitudes from their health history carry over into current treatment.

Gudzune et al ¹⁵ surveyed 6427 patients and compared results according to their BMI. There was a difference in the patients’ comfort level of sharing their health needs based on BMI. Compared with the group that had what is considered a normal BMI of less than 25 kg/m², those with grade 2 obesity with a BMI of 35 to 39 kg/m² had a decreased comfort level in sharing their needs with physicians. ¹⁵ Patients have also reported embarrassment due to beds, gowns, and blood pressure cuffs being too small and not fitting properly.^13,16

Consequences of Obesity

Lack of Medical Resources

There appears to be a general lack of effective counseling and treatment for obese patients. Thuan and Avignon ³ found that 70% of physicians thought it was “very important” to treat eating disorders, but less than 25% believed it was “very important” to refer patients to specialists such as nutrition specialists, dietitians, psychologists, and psychiatrists. ³ Only 37% thought it “very important” to follow up with patients for several years in the management of obesity. ³ Galuska et al ¹⁷ found that less than half of the 12,835 obese participants who visited their physician for a routine checkup were advised to lose weight.

Forman-Hoffman et al ¹⁸ found that 24% of physicians reported good obesity management education in medical school and 31% reported having effective training in their residency programs. Nearly 90% of participants expressed a need for more educational materials to pass out to patients that explain weight management and a need for specialists to whom they could refer their obese patients. ¹⁸ This may imply physicians are not offering advice either because they assume the obese patient will not comply or because they do not believe they have adequate resources to help the patient.

Coping Mechanisms

While there are a variety of ways to cope with weight stigmatisms, many reactions may be counterproductive to losing weight. Individual health consequences may include increased eating, lower physical activity, psychological disorders, stress-induced pathophysiology, and decreased health care utilization. Puhl and Brownell ¹⁹ examined coping responses of obese participants. Their results showed that 79% of participants used eating as a coping mechanism for weight gain. ¹⁹ Seventy-four percent cried and isolated themselves, 73% resorted to negative self-talk, 75% refused to diet, and 25% resorted to physical violence. ¹⁹ Only 25% of participants sought therapy to improve the coping behaviors. ¹⁹

In addition to emotional suffering, overweight patients may avoid health care completely. Drury and Louis ²⁰ explored the relationship between body weight and avoidance of health care. Their findings showed that an increase in BMI was associated with an increase in health care avoidance. ²⁰ Some women avoided health care because of recently gaining weight or a fear of being weighed, of being told to lose weight, or being asked to undress. ²⁰ These results may indicate that insensitive attitudes from health care providers create a lack of trust from patients, many of whom already do not feel secure.

Conclusion

Health care providers and their students report having negative or biased attitudes toward overweight patients. Most physicians surveyed neglected to advise their obese patients to lose weight, even though this may affect a patient’s decision to lose weight. A large percentage of physicians expressed low expectations for patient compliance, making it less rewarding for the physicians who do choose to counsel patients on weight loss. Findings like this are unsettling and require further investigation to identify if physicians are not offering advice because they assume it will not be taken seriously by the obese patient or because they do not believe they have adequate resources to help the patient. Providers described a need for more obesity education within their training programs and information packets to distribute to patients. This information suggests that physicians want to address the problem of obesity but may not know the best way to approach it. The lack of obesity training among education programs may be contributing to biased attitudes. These discreet factors need to be assessed to pinpoint where improvements among providers are most needed.

Overweight and obese patients expressed physical and mental health issues caused by weight stigmatization. Patients have reported a decreased comfort level in sharing their needs with providers and embarrassment due to medical equipment that does not fit properly. With negative reactions to health care, it is possible that weight stigma could contribute to patient noncompliance. Additional studies could identify factors that specifically dissuade patients to not return for care so the medical community can adjust the environment or its behavior to help patients feel comfortable when being treated. Sonographers should be conscious of weight biases and how their attitude and behavior toward an obese patient may affect patient compliance and comfort level to return for future medical care. While obesity certainly makes the sonographer’s task more difficult, empathy for the obese patient as a positive attitude may help trigger a more positive approach overall in that patient’s care and management.