Treating Obese Patients: The Importance of Improving Provider-Patient Interaction

Rebecca M. Puhl, PhD

Disclosures

May 27, 2010

Introduction

Two thirds of Americans are now overweight or obese, so healthcare providers frequently interact with patients who are struggling to lose weight. Indeed, obesity is an important clinical problem that cannot be ignored, and high quality healthcare is critical in efforts to improve health in this population. It is surprising, then, that instead of support and encouragement, obese patients are often treated with insensitivity and judgment, as evidenced by the following experiences related by obese individuals:

"I became very frustrated when a doctor disregarded what I was telling him because he had already made up his mind that obesity was at the root of all my problems."

"My family doctor had a habit of shrugging off my health concerns. The last time I went to him with a problem, he said, 'You just need to learn to push yourself away from the table.'"

"I asked a gynecologist for help with low libido. His response was, 'Lose weight so your husband is interested. That will solve your problem.' I changed doctors after that! And I've told everyone I know to stay away from him."

"I told my doctor that I needed help to lose weight, and he accused me of being a 'closet eater' and wasn't going to put me on anything until I learned to eat better. When I protested, he just laughed. This had a huge impact on me, and I changed doctors the next day.”

"Nurses in the doctors' waiting room stated aloud that if people in waiting room had any willpower that they wouldn't be there. I was very upset but at the time too shy to respond to it."

"My doctor said, 'You are cheating or you would have lost weight.'"

The Problem of Weight Bias

Unfortunately, experiences like these are common for obese patients.[1,2] Research demonstrates that obese patients frequently feel stigmatized in healthcare settings. Overweight or obese patients are more likely to avoid routine preventive care, and when they do seek health services, they may receive compromised care. When obese patients feel stigmatized, they are vulnerable to depression, low self-esteem, anxiety, and suicide. They are less likely to feel motivated to adopt lifestyle changes and may engage in unhealthy eating patterns and avoid physical activity, which can exacerbate weight gain.[3] Simply put, weight stigmatization jeopardizes patients' emotional and physical health.

Providers may unintentionally communicate overt or subtle forms of bias that can negatively affect patients' care and their future utilization of healthcare services. The problem of weight stigma is serious and pervasive, and providers should be aware of this issue in their clinical practice.

Eliminating Weight Bias

Providers can use a number of strategies to increase sensitivity and reduce weight bias in their interactions with patients.

Acknowledge attitudes about obesity. First, it's critical to identify personal attitudes and assumptions about body weight that might unintentionally lead to bias or stigma. Ask yourself the following questions to increase your self-awareness of potential personal biases:

  • Do I make assumptions about a person's character, intelligence, health status, or lifestyle behaviors based only on body weight?

  • Am I comfortable working with patients of all sizes?

  • What kind of feedback do I give obese patients?

  • Am I sensitive to the needs and concerns of obese patients?

  • What are common stereotypes about obese people? Do I believe these to be true or false? What are my reasons for my beliefs?

After reflecting on these questions, look for examples of overweight individuals (eg, patients, family members, friends, coworkers, or even celebrities or athletes) who challenge weight-based stereotypes. Challenge yourself to question your personal assumptions about body weight.

Adopt sensitive language. Effective communication is the key to providing quality healthcare. This can be especially important with obese patients who may have experienced negative interactions with other providers. It is important to approach conversations about body weight and obesity in a sensitive manner.

It can be challenging to discuss health issues related to excess weight while also remaining sensitive to terminology and language that may offend patients. To facilitate positive patient-provider interactions, providers must recognize and use weight-related language with which the patient feels comfortable. For example, some research has examined specific terms that obese patients prefer (or dislike) for describing their body weight. Patients prefer words like "weight," "excess weight," or "body mass index" to "large size," "weight problem," or "unhealthy body weight."[4] It's likely that personal preferences of patients will vary, so it can be helpful to ask them about preferred terms before discussing body weight issues.

Use effective communication strategies. Certain communication strategies can encourage a patient's motivation to engage in healthy lifestyle behaviors without being judgmental or biased. One particularly effective approach is motivational interviewing, which aims to enhance self-efficacy and personal control for behavior change. This approach uses an interactive, empathic listening style to increase motivation and confidence by specifically emphasizing the discrepancy between personal goals and current health behaviors.[5]

The types of questions typically used for this approach are open-ended, nonjudgmental questions, such as:

  • How ready do you feel to change your eating patterns and/or lifestyle behaviors?

  • How is your current weight affecting your life right now?

  • What kinds of things have you done in the past to change your eating?

  • What strategies have worked for you in the past?

  • On a scale from 1-10, how ready are you to make changes in your eating patterns?

These types of questions increase providers' understanding of patients' beliefs, concerns, and expectations; help patients feel understood; and facilitate patients' involvement in decisions that affect their health.

Provide bias-free care. Finally, improving quality of care for obese patients requires implementing strategies to promote bias-free treatment. This means recognition that obesity is a product of many factors -- a complex interaction of genetic, biological, societal, environmental, and psychological contributors. Appreciation of the complex etiology of obesity can help providers avoid placing blame on patients for their obesity. Similarly, it is important for providers to explore all causes of the patient's presenting problems rather than assuming that body weight is the only target for intervention.

When establishing goals for treatment, it is also useful to emphasize the patient's behavioral changes rather than focusing only on the number on the scale. Setting specific, realistic, and measurable goals with respect to eating habits and physical activity levels increases the likelihood that patients will succeed in making healthy changes and communicates the importance of health rather than thinness. Finally, it can be helpful for both providers and patients to discuss the benefits of small weight losses, which can result in considerable improvements in health. Very few obese patients reach their "ideal" weight, but many can experience significant health gains with even a 5% or 10% reduction in their weight.

Conclusion

Healthcare settings should be safe havens where obese patients feel comfortable seeking support not only with weight management but also a broad range of wellness issues. Unfortunately, many patients experience instead shame, stigma, and prejudice. As providers, it is our duty to ensure that all patients are treated with dignity and respect and that their quality of care is not compromised by biased attitudes. By increasing awareness of personal weight-based attitudes and providing sensitive and compassionate care, providers can help create healthcare experiences that instill hope, rather than shame, in this vulnerable patient population.

For more information and free resources about weight bias and stigma, please visit the following website: http://www.yaleruddcenter.org/what_we_do.aspx?id=10

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