How does physician BMI impact patient trust and perceived stigma?

Women's perceptions of body mass graphics and their preferences for weight counselling

Health care providers may lack data-driven guidance about best practises for discussing weight. We assessed women's self-perception of body mass index (BMI) and preferences for weight counselling by provider characteristics and the initiating question. A voluntary, anonymous survey was completed by 756 women (age ≥ 19 year) at our tertiary care obstetrics and gynaecology clinics in autumn 2021. The respondents' height and weight were collected before respondents selected graphics from a validated Body Image Scale that they felt best represented their current body size and which graphs should prompt weight loss or gain recommendations. Respondents were asked their preferences about provider characteristics for discussion about weight and to identify which of six initiating questions from a provider was most and least preferred. Blank responses were allowed. In 708 responses, 366 women (52%) selected the most accurate graphic that corresponded to their BMI; the selected graphic represented a lower than actual BMI in 268 women (38%) and higher in 74 women (10%). In 648 responses, 374 women (58%) preferred a female provider, but provider body shape, ethnicity/race and age were not important to most women. The most preferred question to initiate a discussion about weight was "A lot of women have trouble achieving or maintaining a healthy weight; is that something we can discuss?" in 181 of 555 women (33%), and the least preferred question was "Do you feel like you are at an appropriate weight?" in 172 of 554 women (31%). Provider knowledge about patient preferences regarding questions may facilitate the discussion about weight.

Modeling Behavioral Economics Strategies in Social Marketing Messages to Promote Vegetable Consumption to Low-Resource Louisiana Residents: A Conjoint Analysis

BACKGROUND

Behavioral economics strategies implemented within social marketing campaigns improve eating behavior.

OBJECTIVE

To identify which behavioral economics strategies in social marketing messages particularly messengers, norms, and commitments will promote low-income Louisiana residents to add more vegetables to meals.

DESIGN

Full profile traditional conjoint analysis survey with single concept ratings.

PARTICIPANTS

Purposive sample of low-resource Louisiana residents (N = 213) SETTING: Online survey.

INTERVENTION

Participants rated randomized concepts that featured a messenger and a message.

MAIN OUTCOME MEASURE

Ratings (one to nine) of likelihood to add vegetables to meals.

STATISTICAL ANALYSIS

A model of ratings was generated using mixed-effects multiple regression, which accounted for repeated measurement of participants. Interactions of variables and covariates were modeled.

RESULTS

There was a significant main effect of the messenger variable (P = 0.02) and main effect of the message variable (P = 0.008). Pairwise comparisons demonstrated differences between friend (μ (predicted mean) = 6.80) and mother (μ = 7.06; P = 0.03) as well as friend and normal-weight doctor (μ = 7.03; P = 0.04). Pairwise comparisons demonstrated differences between descriptive norm (μ = 6.79) and grocery list precommitment (μ = 7.02; P = 0.05) along with descriptive norm and injunctive norm (μ = 6.98; P = 0.04). Covariate models demonstrated main effects of race (P = 0.006) and sex (P = 0.0001). There was significant variation in the message variable and frequency of vegetable intake interaction (P = 0.01).

CONCLUSIONS

Both message and messenger variables predicted the likelihood to add vegetables to meals. Race and sex influenced ratings to add vegetables. As reported vegetable consumption increased, behavioral economics messages improved the likelihood to add vegetables to meals. Behavioral economic approaches are well suited to social marketing messages that aim to promote healthy eating behavior in low-income LA residents.

Public trust in physicians: empirical analysis of patient-related factors affecting trust in physicians in China

Background

Trust between the parties is essential for the efficient functioning of the healthcare market. Physician-patient relationship represents an asymmetric information situation and trust in physicians is critical for improving health and wellbeing of patients. In China, trust in physicians appears to be quite low creating conflicts between physicians and patients. This study aims to identify some general factors associated with trust in physicians in general using a nationally representative survey.

Methods

A cross-sectional analysis using data from 2018 China Family Panel Study (CFPS). Survey responses of individuals aged 16 years or above were extracted from CFPS and the final sample consisted of 29,192 individuals. An ordered probit model was used to identify factors causing heterogeneity in the levels of trust in physicians.

Results

Higher educational attainment and having medical insurance coverage are associated with higher likelihood of trusting physicians. Older adults (> = 30 years), males, urban residents, wage-earners, and self-employed persons are less likely to trust physicians. People who are diagnosed as chronic diseases or current smokers indicate lower level of trust in physicians. Higher perceived quality of services improves trust.

Conclusion

Socioeconomically disadvantaged population groups and uninsured individuals are less likely to trust physicians. Health care delivery system needs to address the concerns of these specific population groups to reduce tensions between physicians and patients. Increasing health insurance coverage and offering insurance with low out-of-pocket expenses should reduce the perception that physicians are more guided by their income rather than the wellbeing of patients. The system should also develop a comprehensive bill of rights of patients to improve patient-physician relationship.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12875-022-01832-6.

Weight Communication: How Do Health Professionals Communicate about Weight with Their Patients in Primary Care Settings?

This study aimed to investigate how health professionals (HPs) communicate about weight with their patients. Semi-structured interviews were conducted with 33 health professionals (7 family physicians, 13 nurse practitioners, and 13 dietitians) working in multidisciplinary healthcare settings in Canada. Thematic analysis revealed four main approaches used by HPs to communicate about weight: 1) Analyzing patient perspectives, 2) focusing on overall health rather than weight, 3) directly addressing the topic, and 4) avoiding the topic. The approach chosen was influenced by HPs' outlook on obesity; for example, those who believed obesity to be a chronic disease did not hesitate to communicate about weight. However, some HPs who reported having obesity mentioned avoiding the topic of weight with their patients and emphasized the importance of establishing a trusting relationship with patients before addressing the topic. The approach chosen by HPs also seemed to be influenced by patient receptiveness, level of readiness, and motivation. Weight communication can be sensitive and the approach used to begin the topic of weight may differ based on patient- and HP factors. Future clinical practice guidelines may benefit from shifting toward communicating about modifiable risk factors rather than weight.

Interphysician weight bias: A cross-sectional observational survey study to guide implicit bias training in the medical workplace

OBJECTIVES

Implicit bias contributes to both health care disparities and professional limitations, and it exists among physicians. Prior literature has described physician weight bias (WB) toward patients, but little research has investigated interphysician WB. This study describes the prevalence of interphysician implicit WB and investigates the relationships between implicit, explicit, and professional biases. The authors hypothesized that the majority of physicians possess interphysician implicit WB and that the degree of implicit bias has a direct relationship with explicit and professional WB.

METHODS

In this cross-sectional study, a survey was used to measure interphysician implicit, explicit, and professional WB. It included adaptations of two previously validated measures (the Implicit Association Test and the Crandall Anti-fat Attitudes Questionnaire) and an investigator developed and tested Professional Weight Bias Scale. The survey was distributed electronically via medical society message boards, email lists, and social media groups.

RESULTS

A total of 620 physicians and medical students participated. Fifty-eight percent were female, ages ranged from 22 to 83 years (mean = 44 years), and body mass index (BMI) ranged from 16 to 59 (mean = 26). Descriptive analyses revealed that 87% had some degree of implicit interphysician antifat bias, with 31% and 34% categorized as moderate and severe, respectively. Correlation and multiple regression analyses revealed that male sex, increased age, and decreased BMI were related to increased implicit bias, controlling for all other factors. Furthermore, implicit, explicit, and professional bias all had significant, direct relationships with each other.

CONCLUSIONS

Our findings highlight the prevalence of interphysician implicit WB; the strong correlations between implicit, explicit, and professional WB; and the potential disparities faced by physicians with obesity. These results may be used to guide implicit bias training for a more inclusive medical workplace.

Clinical encounters about obesity: Systematic review of patients' perspectives

Guidelines recommend clinicians intervene on obesity but it is unclear how people with overweight react. In this systematic review, we searched 20 online databases for qualitative studies interviewing people with overweight or obesity who had consulted a primary care clinician. Framework synthesis was used to analyse 21 studies to produce a new theoretical understanding. Consultations in which patients discussed their weight were more infrequent than patients would have liked, which some perceived was because they were unworthy of medical time; others that it indicated doctors feel being overweight is not a serious risk. Patients reported that doctors offered banal advice assuming that the patient ate unhealthily or was not trying to address their weight. Patients reported doctors assumed that their symptoms were due to overweight without a proper history or examination, creating concern that serious illness may be missed. Patients responded positively to offers of support for weight loss and active monitoring of weight. Patients with overweight internalize weight stigma sensitizing them to clues that clinicians are judging them negatively, even if weight is not discussed. Patients' negative experiences in consultations relate to perceived snap judgements and flippant advice and negative experiences appear more salient than positive ones.

The challenge for global health systems in preventing and managing obesity

Few health crises have been as predictable as the unfolding obesity pandemic. Clinical and public health services remain the front line of efforts to reduce the burden of obesity. While a range of clinical practice guidelines exist, the need for clinical interventions exceeds the capacity of health systems to provide care for those affected with obesity, and routine clinical practices fall far short of guidelines recommendations even in high-income countries. In this manuscript, we discuss current recommendations regarding obesity interventions and key challenges facing global health systems in managing the health needs of people with obesity. Improving the provision of obesity-related health care is a considerable challenge and will require changing existing perceptions of obesity as a matter of personal failure to its recognition as a disease, innovative approaches to health system reform, clinician capacity building and implementation support, a focus on prevention, and wise resource allocation. Leadership from governments, the medical profession, and patient and community groups to address the issues raised in this manuscript is urgently needed to address the growing health concern.

Factors affecting access and use of preventive and weight management care: A public health lens

Obesity is an important risk factor for various chronic diseases. While people with obesity use the health system more and incur higher costs, they may forego using preventive care services (e.g., gynecological cancer screenings) due to issues of service use and service access. The aim of this paper was to use a public health lens to elucidate system level factors that affect healthcare access and utilization for preventive and weight management care by patients with obesity. Some elucidated factors include lack of access to a Primary Care Provider (PCP) and multidisciplinary healthcare settings, gender of the PCP, duration of medical visits and health professionals' attitudes about obesity. We highlight potential strategies for leaders to use when improving access and use of health services by patients with obesity in Canada and the need for future empirical studies in this research area.

Clinical Nutrition Education of Doctors and Medical Students: Solving the Catch 22

There is a well-documented pandemic of malnutrition. It has numerous sequelae, including physical and psychological ill health, early death, and socioeconomic burden. The nutrition landscape and dynamics of the nutrition transition are extremely complex, but one significant factor in both is the role of medical management. Doctors have a unique position in society from which to influence this scenario at global, public, and personal levels, but we are failing to do so. There are several reasons for this, including inadequate time; historical educational bias towards disease and therapeutic intervention-rather than diet, lifestyle, and prevention; actual or perceived incompetency in the field of nutrition; confusion or deflection within medicine about whose role(s) it is on a medical team to address nutrition; and public confusion about whom to turn to for advice. But the most fundamental reason is that current doctors (and thus the trainers of medical students) have not received-and future doctors are thus still not receiving-adequate training to render them confident or competent to take on the role. A small number of important educational approaches exist aimed at practicing doctors and medical students, but the most effective methods of teaching are still being evaluated. Without properly trained trainers, we have no one to train the doctors of tomorrow. This is a "catch 22." To break this deadlock, there is an urgent need to make appropriate nutrition training available, internationally, and at all levels of medical education (medical students, doctors-in-training, and practicing doctors). Until this is achieved, the current pandemic of nutrition-related disease will continue to grow. Using important illustrative examples of existing successful nutrition education approaches, we suggest potential approaches to breaking this deadlock.

Letters designed with behavioural science increase influenza vaccination in Medicare beneficiaries

The influenza ('flu') vaccination is low cost¹ and effective, typically reducing the likelihood of infection by 50-60%². It is recommended for nearly everyone older than 6 months of age³; yet, only 40% of Americans are immunized each year. Vaccination rates are higher among at-risk groups, such as those ≥65 years of age, but still only 6 in 10 receive it⁴. There have been numerous attempts to improve vaccination rates using strategies such as school-based programmes, financial incentives and reminders, but these have generally had limited success^5-7. Of the attempts that are successful, most are expensive-limiting scalability-and have not been evaluated in the elderly⁸. Conversely, lower-cost interventions, such as mailed information, hold promise for a scalable solution, but their limited effectiveness may result from how they have been designed. We randomly assigned 228,000 individuals ≥66 years of age to one of five versions of letters intended to motivate vaccination, including versions with an implementation intention prompt and an enhanced active choice implementation prompt. We found that a single mailed letter significantly increased influenza vaccination rates compared with no letter. However, there was no difference in vaccination rates across the four different letters tailored with behavioural science techniques.

Preferences for physician weight status among women with overweight

BACKGROUND

Women with overweight experience stigma in clinical interactions. Emerging evidence suggests that one near-term approach to offset the negative consequences of weight stigma could be to capitalize on benefits of patient-physician weight concordance. However, it is likely that patient attitudes towards physicians with overweight are complicated and multifaceted and may include stigmatization of providers with overweight.

METHODS

Two-hundred ninety-eight women with overweight completed an online questionnaire and indicated preference for a physician who is 'overweight', 'not overweight', or indicated no preference. Participants provided reasons for their choice and answered questions about their weight-related beliefs and experiences.

RESULTS

The majority of women indicated no weight preference (63%), and a portion (36%) of the sample explicitly preferred physicians who are not overweight. Reasons provided for these preferences were primarily based on stereotyped notions of physician aptitude based on weight. Compared with having no preference, those who preferred physicians who are not overweight had fewer previous negative weight-related physician interactions and had increased beliefs about the controllability of weight.

CONCLUSIONS

These findings elucidate patient attitudes towards physicians with overweight in a sample at increased risk for weight stigmatization. Findings underscore the need for stigma-reducing interventions so that clinical experiences for both women and physicians with overweight can be improved.

Obesity and Sexual Dysfunction: Making the Connection

Understanding the relationship between the two may motivate patients to discuss weight loss.

The association between parent-reported provider communication quality and child obesity status: Variation by parent obesity and child race/ethnicity

OBJECTIVE

To examine the association between healthcare provider communication quality and child obesity status, and the role of parent obesity and child race/ethnicity regarding this association.

METHODS

We conducted a cross-sectional secondary data analysis with the 2011-2013 Medical Expenditures Panel Survey of parents with children ages 6-12 (n=5390). We used multivariable logistic regression to examine the association of parent-reported healthcare provider communication quality (explaining well, listening carefully, showing respect, and spending enough time) with child obesity status, and effect modification by parent obesity and child race/ethnicity.

RESULTS

Parents of obese children were more likely to report that their child's healthcare provider listened carefully (OR=1.41, p=0.002) and spent enough time (OR=1.33, p=0.022) than parents of non-obese children. Non-obese parents of obese children experienced better communication in the domains of listening carefully (p<0.001) and spending enough time (p=0.007). Parents of obese non-Hispanic Asian children and non-Hispanic Black children were more likely to report that providers explained things well (p=0.043) and listened carefully (p=0.012), respectively.

CONCLUSION

Parents of obese children experienced better communication if parents were non-obese or children were non-Hispanic Black or Asian.

PRACTICE IMPLICATIONS

Healthcare providers should ensure effective communication with obese parents of obese children.

Why Australia needs to define obesity as a chronic condition

Background

In Australia people with a diagnosed chronic condition can be managed on unique funded care plans that allow the recruitment of a multidisciplinary team to assist in setting treatment goals and adequate follow up. In contrast to the World Health Organisation, the North American and European Medical Associations, the Australian Medical Association does not recognise obesity as a chronic condition, therefore excluding a diagnosis of obesity from qualifying for a structured and funded treatment plan.

Body

The Australian guidelines for management of Obesity in adults in Primary Care are structured around a five step process -the ‘5As’: Ask & Assess, Advise, Assist and Arrange’. This article aims to identify the key challenges and successes associated with the ‘5As’ approach, to better understand the reasons for the gap between the high Australian prevalence of overweight and obesity and an actual diagnosis and treatment plan for managing obesity. It argues that until the Australian health system follows the international lead and defines obesity as a chronic condition, the capacity for Australian doctors to diagnose and initiate structured treatment plans will remain limited and ineffective.

Conclusion

Australian General Practitioners are limited in their ability manage obesity, as the current treatment guidelines only recognise obesity as a risk factor rather than a chronic condition.

Provider communication quality: influence of patients' weight and race

OBJECTIVE

To examine the relationship between patient weight and provider communication quality and determine whether patient race/ethnicity modifies this association.

METHODS

We conducted a cross-sectional analysis with 2009-2010 medical expenditures panel survey-household component (N=25,971). Our dependent variables were patient report of providers explaining well, listening, showing respect, and spending time. Our independent variables were patient weight status and patient weight-race/ethnicity groups. Using survey weights, we performed multivariate logistic regression to examine the adjusted association between patient weight and patient-provider communication measures, and whether patient race/ethnicity modifies this relationship.

RESULTS

Compared to healthy weight whites, obese blacks were less likely to report that their providers explained things well (OR 0.78; p=0.02) or spent enough time with them (OR 0.81; p=0.04), and overweight blacks were also less likely to report that providers spent enough time with them (OR 0.78; p=0.02). Healthy weight Hispanics were also less likely to report adequate provider explanations (OR 0.74; p=0.04).

CONCLUSION

Our study provides preliminary evidence that overweight/obese black and healthy weight Hispanic patients experience disparities in provider communication quality.

PRACTICE IMPLICATION

Curricula on weight bias and cultural competency might improve communication between providers and their overweight/obese black and healthy weight Hispanic patients.

Factors that influence physicians' and medical students' confidence in counseling patients about physical activity

Less than half of US adults and two-thirds of US high school students do not meet current US guidelines for physical activity. We examined which factors promoted physicians' and medical students' confidence in counseling patients about physical activity. We established an online exercise survey targeting attending physicians, resident and fellow physicians, and medical students to determine their current level of physical activity and confidence in counseling patients about physical activity. We compared their personal level of physical activity with the 2008 Physical Activity Guidelines of the US Department of Health and Human Services (USDHHS). We administered a survey in 2009 and 2010 that used the short form of the International Physical Activity Questionnaire. A total of 1,949 individuals responded to the survey, of whom 1,751 (i.e., 566 attending physicians, 138 fellow physicians, 806 resident physicians, and 215 medical students) were included in this analysis. After adjusting for their BMI, the odds that physicians and medical students who met USDHHS guidelines for vigorous activity would express confidence in their ability to provide exercise counseling were more than twice that of physicians who did not meet these guidelines. Individuals who were overweight were less likely to be confident than those with normal BMI, after adjusting for whether they met the vigorous exercise guidelines. Physicians with obesity were even less likely to express confidence in regards to exercise counseling. We conclude that physicians and medical students who had a normal BMI and met vigorous USDHHS guidelines were more likely to feel confident about counseling their patients about physical activity. Our findings suggest that graduate medical school education should focus on health promotion in their students, as this will likely lead to improved health behaviors in their students' patient populations.

Patients who feel judged about their weight have lower trust in their primary care providers

OBJECTIVE

To evaluate whether overweight and obese patients have less trust in their primary care providers (PCPs) if they feel judged about their weight by these PCPs.

METHODS

We conducted a national internet-based survey of 600 adults engaged in primary care with a BMI ≥ 25 kg/m(2) in 2012. Our dependent variable was high patient trust in their PCP (score ≥ 8/10). Our independent variable was "feeling judged about my weight by my PCP" dichotomized as "often/sometimes" versus "never." We conducted a multivariate logistic regression model adjusted for patient and PCP factors using survey weights.

RESULTS

Overall, 21% felt that their PCP judged them about their weight. Respondents who perceived judgment were significantly less likely to report high trust in their PCP [OR 0.55, 95% CI 0.31-0.98].

CONCLUSION

While only a fifth of overweight and obese patients perceived weight-related judgment from their PCPs, these patients were significantly less likely to report high trust in these providers. Given patients' decreased trust in providers who convey weight-related judgment, our results raise concerns about potential effects on the doctor-patient relationship and patient outcomes.

PRACTICE IMPLICATIONS

Addressing provider stigma toward patients with obesity could help build trust in these patient-provider relationships and improve quality of care.

Prior doctor shopping resulting from differential treatment correlates with differences in current patient-provider relationships

OBJECTIVE

To determine the prevalence of doctor shopping resulting from differential treatment and to examine associations between this shopping and current primary care relationships.

METHODS

In 2012, a national internet-based survey of 600 adults receiving primary care in the past year with a BMI ≥ 25 kg/m(2) was conducted. Our independent variable was "switching doctors because I felt treated differently because of my weight." Logistic regression models to examine the association of prior doctor shopping with characteristics of current primary care relationships: duration, trust in primary care provider (PCP), and perceived PCP weight-related judgment, adjusted for patient factors were used.

RESULTS

Overall, 13% of adults with overweight/obesity reported previously doctor shopping resulting from differential treatment. Prior shoppers were more likely to report shorter durations of their current relationships [73% vs. 52%; p = 0.01] or perceive that their current PCP judged them because of their weight [74% vs. 11%; p < 0.01] than nonshoppers. No significant differences in reporting high trust in current PCPs were found.

CONCLUSIONS

A subset of patients with overweight/obesity doctor shop resulting from perceived differential treatment. These prior negative experiences have no association with trust in current relationships, but our results suggest that patients may remain sensitive to provider weight bias.

Perceived judgment about weight can negatively influence weight loss: a cross-sectional study of overweight and obese patients

OBJECTIVE

To examine the association between patient-perceived judgments about weight by primary care providers (PCPs) and self-reported weight loss.

METHODS

We conducted a national internet-based survey of 600 adults engaged in primary care with a body mass index (BMI)≥25 kg/m(2) in 2012. Our weight loss outcomes included attempted weight loss and achieved ≥10% weight loss in the last 12 months. Our independent variable was "feeling judged about my weight by my PCP." We created an interaction between perceiving judgment and PCP discussing weight loss as an independent variable. We conducted a multivariate logistic regression model adjusted for patient and PCP factors using survey weights.

RESULTS

Overall, 21% perceived that their PCP judged them about their weight. Respondents who perceived judgment were significantly more likely to attempt weight loss [odds ratios (OR) 4.67, 95% confidence interval (CI) 1.96-11.14]. They were not more likely to achieve ≥10% weight loss [OR 0.87, 95%CI 0.42-1.76]. Among patients whose PCPs discussed weight loss, 20.1% achieved ≥10% weight loss if they did not perceive judgment by their PCP as compared to 13.5% who perceived judgment.

CONCLUSIONS

Weight loss discussions between patients and PCPs may lead to greater weight loss in relationships where patients do not perceive judgment about their weight.

[Physician's role in "medical drama" pitfall? Reflection of stereotypical images of doctors in context of contemporary doctor's series]

In contemporary U.S. doctor's series, the characters are usually represented by good-looking or typical character actors. The aim of our pilot study was to investigate whether the long-term impact of this format on German television viewers could have an influence on the choice of doctor in Germany. Two different groups of people anticipating TV consumption patterns were questioned: a first group of younger adults who knew theTV series was asked to judge their doctor choice using a web-based survey tool with respect to three criteria (sympathy, expertise and own treatment preference). The second group of adults beyond the 40th year of life who need not know theTV series were shown photos of the serial figures. Study participants should select the "doctor" of which they would most likely want to be treated and this based on two predetermined reasons (sympathy or expertise). Our results indicate that stereotypical images of doctors found high approval only in the first group of people, while the participants in the second group decided in majorityfora more realistic representation of average appearance.