Managing Anti-Fat Stigma in Primary Care: An Observational Study

Factors Influencing Referral for Bariatric Surgery by Primary Care Physicians in Northern Israel

PURPOSE

Obesity is a chronic metabolic disease with global distribution among adults and children which affects daily functioning and ultimately quality of life. Primary care physicians (PCPs) provide an important role for the treatment of severe obesity. Better understanding of obesity and its treatment options may increase patients' referral rates to the various treatment modalities, including metabolic/bariatric surgery (MBS).

MATERIALS AND METHODS

A quantitative cross-sectional study used a self-reported questionnaire among PCPs of Clalit Health Services (CHS) in Northern Israel. The quantitative questionnaire examined the PCP's knowledge, opinions, attitude, and approaches to managing severe obesity.

RESULTS

A total of 246 PCPs from Northern Israel filled the questionnaire (42.9%), the majority were Muslim Arabs (54.5%), who gained their medical degree outside of Israel (73.8%) and practicing for over 10 years (58.8%). 64.3% of PCPs had a high workload (over 100 appointments per week), 77.1% did not know the definition of severe obesity, and 69.17% did not attend educational meetings regarding obesity during the previous year. The referral rate for MBS was 50.4% ± 23.3. Two prognostic factors that had a statistically significant effect on the referral rate for bariatric surgery were the total appointments per week, and the number of practice years. Both had a negative association.

CONCLUSION

The knowledge and referral rates for bariatric surgery are higher among PCPs with lower workload and relatively fewer practice years. Workshops and annual training courses may fortify knowledge and awareness for the treatment of obesity, which in turn could increase the referral rate for MBS.

Weight bias and stigma in healthcare: What are we doing about it?

Weight bias and weight stigma is present in healthcare settings negatively affecting people with obesity. Healthcare professionals should be aware of how their potential bias and stigma may be impacting clients with obesity. With obesity projected to rise among the world, the healthcare environment needs to be more accepting and accommodating.

Patient Preferences for Attributes of Health Canada Approved Weight Loss Medications Among Adults Living with Obesity in Canada: A Qualitative Study

PURPOSE

Obesity is a complex disease with negative impacts on physical and mental health. The treatment of obesity is an area where shared decision making and patient preferences play an important role. Recommendations surrounding weight loss medications are evolving and only recently, with the publication of the 2020 Canadian Obesity Management Clinical Guidelines, pharmacotherapy has become a recommended alternative for obesity management. Guidelines recommend three medications: orlistat, liraglutide, and naltrexone/bupropion. This study sought to identify medication attributes relevant to patients starting pharmacotherapy for weight management.

PATIENTS AND METHODS

Semi-structured focus groups and interviews were conducted with Canadian residents who were ≥18 years of age and were living with obesity (body mass index [BMI] ≥30kg/m² or ≥27kg/m² with adiposity-related complications). Sessions were conducted virtually, audio recorded, and transcribed. Two team members used a combination of inductive and deductive coding to independently code the data. A final coding template was agreed upon through discussion.

RESULTS

A total of 21 individuals participated (85.7% female, 76.2% ≥40 years of age) with the average BMI being 44.3 kg/m². Participants touched upon many attributes which were categorized into five categories: 1) cost, 2) regimen, 3) side effects, 4) benefits, and 5) non-medication attributes. Cost of medications, lack of coverage by insurance companies, and stigma were identified as major barriers to accessing medications. There was consensus in the desire for a simple regimen, however there was heterogeneity among opinions on tolerability of side effects, desired benefits, and route of administration.

CONCLUSION

This study identified attributes that influenced patient's decisions when considering a new anti-obesity medication. Understanding these attributes can assist clinicians in shared decision-making. This study highlighted the stigma that is prevalent among providers and the need for education. Further research should be conducted to understand the tradeoffs patients in our study make between the identified attributes.

A Community Jury on initiating weight management conversations in primary care

Background

Current guidelines recommend that patients attending general practice should be screened for excess weight, and provided with weight management advice.

Objective

This study sought to elicit the views of people with overweight and obesity about the role of GPs in initiating conversations about weight management.

Methods

Participants with a body mass index ≥25 were recruited from a region in Australia to take part in a Community Jury. Over 2 days, participants (n = 11) deliberated on two interconnected questions: ‘Should GPs initiate discussions about weight management?’ And ‘if so, when: (a) opportunistically, (b) in the context of disease prevention, (c) in the context of disease management or (d) other?’ The jury deliberations were analysed qualitatively to elicit their views and recommendations.

Results

The jury concluded GPs should be discussing weight management, but within the broader context of general health. The jury were divided about the utility of screening. Jurors felt GPs should initiate the conversation if directly relevant for disease prevention or management, otherwise GPs should provide opportunities for patients to consent to the issue being raised.

Conclusion

The jury's verdict suggests informed people affected by overweight and obesity believe GPs should discuss weight management with their patients. GPs should feel reassured that discussions are likely to be welcomed by patients, particularly if embedded within a more holistic focus on person‐centred care.

Public contribution

Members of the public took part in the conduct of this study as jurors, but were not involved in the design, analysis or write‐up.

Smoking self-concept moderates the effects of self-affirmation on smoking-related beliefs and behavioral intentions

OBJECTIVE

Smoking stigmatization has been shown to hinder cigarette smoking cessation, especially among individuals with a strong smoker identity. Self-affirmation, a psychological threat-management coping strategy, can promote smoking cessation, and may mitigate the adverse consequences of stigmatization.

DESIGN

Data from an online sample of 1,020 U.S. adult smokers were analyzed using multiple linear regression.

MAIN OUTCOME MEASURES

Participants completed a self-affirmation (or no-affirmation control) writing task before viewing a smoking stigma (or non-stigma control) anti-smoking public service announcement video. Participants then reported smoking-related cognitions and behavioral intentions.

RESULTS

Among participants with strong-but not weak-ties to a smoker identity (smoking self-concept), self-affirming led to higher quit intentions compared to the control condition. Among participants with weak-but not strong-smoking self-concepts, those who self-affirmed had lower intentions to switch completely to e-cigarettes relative to the control condition. Exposure to stigmatization reduced intentions to seek cessation counseling, particularly among those with weak smoking self-concepts.

CONCLUSION

Findings demonstrate the critical role that smoking identity centrality plays in moderating reactions to both affirming and stigmatizing stimuli. Additional research is needed to better understand how self-affirmation and stigma-reduction interventions can be tailored and implemented in natural contexts.

Transforming Health Experience and Action through Shifting the Narrative on Obesity in Primary Care Encounters

We sought to understand the impact of primary care conversations about obesity on people's everyday life health experience and practices. Using a dialogic narrative perspective, we examined key moments in three very different clinical encounters, the patients' journals, and follow-up interviews over several weeks. We trace how people living with obesity negotiate narrative alternatives that are offered during clinical dialogue to transform their own narrative and experience of obesity and self. Findings provide pragmatic insights into how providers can play a significant role in shifting narratives about obesity and self and how such co-constructed narratives translate into change and tangible health outcomes in people's lives.

Rising prevalence of BMI ≥40 kg/m2 : A high-demand epidemic needing better documentation

Whilst previously rare, some surveys indicate substantial increases in the population with body mass index (BMI) ≥40 kg/m2 since the 1980s. Clinicians report emerging care challenges for this population, often with high resource demands. Accurate prevalence data, gathered using reliable methods, are needed to inform health care practice, planning, and research. We searched digitally for English language sources with measured prevalence data on adult BMI ≥40 collected since 2010. The search strategy included sources identified from recent work by NCD-RisC (2017), grey sources, a literature search to find current sources, and digital snowball searching. Eighteen countries, across five continents, reported BMI ≥40 prevalence data in surveys since 2010: 12% of eligible national surveys examined. Prevalence of BMI ≥40 ranged from 1.3% (Spain) to 7.7% (USA) for all adults, 0.7% (Serbia) to 5.6% (USA) for men, and 1.8% (Poland) to 9.7% (USA) for women. Limited trend data covering recent decades support significant growth of BMI ≥40 population. Methodological limitations include small samples and data collection methods likely to exclude people with very high BMIs. BMI ≥40 data are not routinely reported in international surveys. Lack of data impairs surveillance of population trends, understanding of causation, and societal provision for individuals living with higher weights.

Knowledge brokering: (mis)aligning population knowledge with care of fat bodies

OBJECTIVE

Two prominent Canadian knowledge brokers aim to influence how primary care clinicians address obesity, through the dissemination of texts: the Canadian Task Force on Preventive Health Care (guideline) and the Canadian Obesity Network (5As). While written for the same clinician and adult patient population, the recommendations differ. This analysis highlights active decisions that produced the difference.

METHODS

Frame analysis of the guideline and 5As texts.

RESULTS

The brokers both frame obesity as a chronic and pathological threat to health, at least to a point. The guideline texts frame obesity primarily as a sign of a behavioural problem, discrediting or ignoring many complicating sources of knowledge. In contrast, the 5As frames obesity as complex through diversifying the knowledge foundation embedded in the texts (e.g., including fat-related stigmatisation; health status differences among those classified as obese). Both de-emphasize social and environmental determinants of weight and health.

CONCLUSION

Frames of problems used by brokers are not neutral, nor are decisions about how knowledge is excluded and included. Knowledge brokering, no matter how scientific and systematic, is limited by its frame. Recognizing the limits of each frame supports reflexivity in knowledge brokering and interventions taken to enhance health.