Cases in Health Disparities: Bias Against the Obese Patient and Approaches for Managing It

Désirée Lie, MD, MSEd

Disclosures

February 17, 2010

Commentary

Despite the longstanding availability of evidence-based guidelines to help physicians and public health clinicians combat the epidemic of obesity, the prevalence of obesity is expected to continue to increase in forthcoming decades.[1,2,3] Multiple societal influences, including food advertisement, portion sizes, cultural beliefs, sedentary behaviors and lifestyles, and lack of awareness, contribute to the rise of obesity as the most preventable cause of cardiovascular disease. Physicians (particularly primary care providers) are on the frontline for prevention, but barriers to obesity management continue to exist.[4,5,6]

Antiobesity Attitudes

Negative attitudes toward obesity have been documented in many domains of life, including work, education, and healthcare.[7,8,9] Strong implicit bias against obese persons has been demonstrated among health professionals in the United States and other developed countries -- even among those who are themselves overweight or who specialize in weight management.[10] A gap exists between explicit and implicit bias in attitudes toward obesity. One study showed that attributing obesity to biological rather than psychosocial causes can reduce negative implicit antifat attitudes.[11]

A survey[12] of general practitioners (GPs) in the United Kingdom found that, in general, GPs did not believe that obesity management belonged in the medical domain and supported a coherent belief model that endorsed a psychological and social (rather than biological) cause for obesity. Consequently, they were reluctant to recommend biomedical treatment strategies for obese patients. Another study found that only 3% of GPs would refer obese patients for behavioral therapy and only 23% would refer qualified morbidly obese patients to a surgeon for bariatric surgery.[13]

Other research from the United Kingdom indicates that GPs do not believe that weight management is within their professional domain.[14,15] In an Israeli study, family physicians and advanced practice nurses also expressed little enthusiasm for weight management because they believed that they could not make a positive difference in outcomes.[16,17] Negative attitudes toward obesity have also been reported among nurses,[18] and differential attitudes about weight loss depending on a patient's gender have been documented among physicians.[19] Patients seeking weight management have indicated that their physicians underaddressed the issue of weight. These patients wanted more counseling than they received from their physicians, with a specific focus on weight-loss goals, dietary advice, and exercise recommendations.[20]

Of greater concern, obese women (mean age 44 years, mean BMI 35.2) surveyed in another US study[21] expressed low satisfaction with their physicians' expertise and knowledge of obesity, although they were satisfied with their physicians' general knowledge and care of their health. Half of these women reported that their physicians did not recommend any of 10 common weight-loss methods.

Approach to Patients With Obesity

Physicians with unconscious biases may automatically classify patients into particular groups (eg, unemployed, alcoholic, white, Hispanic) and unwittingly contribute to disparities by making different clinical decisions for such groups based on assumptions on probable adherence to treatment or treatment efficacy.[22,23,24] For example, clinical decision-making for thrombolysis and cardiac catheterization has been linked to subconscious racial bias on the part of physicians.[25,26]

Patients who detect negative biases may ignore the cues or react in ways that have long-term effects on their attitudes toward health and adherence to physician advice. One such possible reaction has been described as stereotype threat,[27,28] a set of physiologic and psychologic reactions (including anxiety and negative emotions), that are triggered by negative stereotypes associated with the individual's group status (such as obesity). Stereotype threat can lower performance[29] through anxiety and reduced self-expectation and can result in disidentification and disengagement. Consequences can include patients not expending effort, discounting feedback, and ignoring recommendations from their physicians.[30,31] Any or all of these responses may potentially lead to reduced adherence to treatment and follow-up.[32,33]

Dr. A may have unwittingly expressed an implicit antifat bias toward Cindy through her recommendation that Cindy did not need a Pap test or through her body language or general communication style. Antifat bias among health professionals is not uncommon[10] and tends to be implicit rather than explicit because of social pressure for healthcare providers to show tolerance and cultural sensitivity.

Some evidence suggests that motivated individuals who are made aware of their personal implicit biases can mentally alter them.[34] One way of developing such awareness is to take the Implicit Association Test , a brief, online, interactive exercise that measures implicit bias by linking pictures and words (associated with such features as race, body size, or disability) to positive or negative characteristics.[35,36,37] Reflecting on one's own IAT results either individually or in a group can enhance understanding and acceptance of implicit bias and lead to behavior changes that actively address potential negative consequences of this bias.[38,39]

Techniques for counteracting the effect of stereotype threat on patient behaviors are available to clinicians. One technique involves providing an identity-safe environment[40] for patients in the medical encounter. Other techniques include allowing patients to "self-affirm"[41]their strengths and abilities; providing a high standard for patients to meet, showing trust for their' ability to change their behavior; and giving constructive performance feedback.

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