We found that obese patients’ perceptions of physician behavior varied and could serve either to further motivate African Americans to attempt weight loss or act as a barrier, driving them away from seeking the assistance they need. Most notably, participants disliked the word ‘obese,’ viewing it as an emotionally charged term and lacking understanding of its clinically definition. Prior studies have reported similar objections to the use of certain descriptors of excess weigh including both ‘obesity’ and ‘fatness,’ with more neutral terms, such as ‘weight’ or ‘excess weight’ being preferred.16
Much of the opposition to the use of these terms likely stems from the stigmatization of obesity, which has been reported even in the medical community.17–20
While feelings of discrimination, intolerance, and disrespectful behaviors are still reported, a study by Anderson and Wadden suggests that interactions with physicians concerning weight may be improving in more recent years, with fewer individuals reporting negative interactions with health-care professionals, and an increase in the sense of satisfaction with medical care received.21
Despite these findings, more improvement is needed, as evidenced by data that suggest many obese patients still do not routinely seek weight management advice from their physicians.12
The manner in which physicians communicate with patients about obesity plays an important role in how patients process weight-related messages and could affect the efficacy of physician attempts at weight managment. In this study, obese urban African Americans perceived a direct, respectful approach focused on the positives of weight reduction as an effective motivator for weight loss. Prior studies have similarly shown that health counseling that uses positive framing, such as emphasizing the health benefits of weight loss, can increase patient receptivity compared to counseling that is negatively framed, such as focusing on the health risks of remaining obese.15,22
While it remains unknown if this contextual framing has an impact on the rates of patient implemention of behavioral change for weight loss, it is recognized that physicians’ manners in discussing weight appear to affect patient receptiveness to obesity counseling and education, a critical first step in motivating lifestyle change.23
Moreover, participants in our study expressed a desire for physicians to fully assess patient readiness to address their weight and review prior experiences with weight loss attempts in order to deal with potential obstacles. This finding suggests that increased training and education of physicians to properly assess readiness to change and self-efficacy as suggested by Motivational Interviewing techniques24,25
may be an effective way to improve patient-provider communication regarding obesity.
In addition to addressing how counseling is delivered, the content of weight management discussions must also be examined. Consistent with prior research, participants in our study focused heavily on the need for physicians to provide more specific and personalized advice. Potter et al. also reported patients prefer explicit instruction on nutrition and diet, weight loss goals, and exercise recommendations rather than a discussion of the health consequences of obesity.26
While particiants in our study had mixed reactions to the use of scare tactics, no prior studies have exmained patient response to or effectiveness of scare tactics for weight management. The use of scare tactics in public health campaigns remains controversial and generally unaccepted; however, it has been shown to be effective in decreasing smoking rates.27
One of the major challenges in improving the management of obesity by primary care providers remains bridging the gap between patient and physician expectations. While patients desire more assistance and specific information from their physicians, physicians have been reported to have low self-perceived confidence in treating obesity and a belief that patients are not motivated enough to lose a significant amount of weight.10,28,29
Limited reimbursement and time constraints present further barriers to physician counseling.10,11
Our study findings reinforce the patients’ perception that physicians have the knowledge, skills, and time to provide the necessary weight management counseling. It is imperative for physicians to recognize this discrepancy between patient and provider perceptions and expectations regarding weight management as a first step towards addressing it.
The findings from this study have limited generalizabilty. The results presented here are based on focus group data from urban obese African Americans receiving primary care services at an academic health center. The views expressed may not be generalizable to other racial or ethnic groups, or to African Americans residing in or receiving health care in other settings. In addition, all group participants reported prior attempts at weight loss; thus, our findings may differ from African Americans who have not yet attempted to lose weight. Further, no data on educational and income levels were collected. Importantly, approximately 20% of the focus group participants were known to the nurse pracitioner who moderated the discussions; however, only about 10% would identify her as their primary provider. While we acknowlege this may have hindered frank discussion regarding physician behaviors and participant perceptions, it should be noted that the majority of these participants participated in the last focus groups with both genders. No new themes emerged in these groups, and, more importantly, the discussions encompassed a similar range of themes as earlier groups, and participants expressed similar emotional levels during the discussions. Since participant recruitment consisted primarily of physician referral rather than patient self-referral, the potential for selection bias exists. Although physicians may have been more likely to refer patients with whom they have good relationships or those they have counseled on weight management, participants did identify several physician behaviors that were either lacking entirely or not well received. Finally, a substantial body of existing research in this area with which to triangulate the qualitative data is lacking. More research is needed to extend our findings to diverse patient populations and should include the perspectives of patients residing in many geographic areas and receiving care in varying settings, including private and community practices.
In conclusion, the results of our study highlight the need for physicians to be cognizant of the potential unintended consequences of the current techniques they use to counsel African Americans about obesity. Physicians must be aware that their patients may respond unexpectedly if approached in a manner they percieve as disrepectful, condescending, emotionless, or non-supportive. Physicians should minimize if not completely avoid using the word ‘obese’ in the clinical setting with African Americans and provide more information on clinical measures of excess of weight, including BMI. Further, physicians should discuss the significance of excess weight as it relates to individual health risks. Providers must be cautious when employing scare tactics as a means to promote lifestyle change to achieve weight reduction as not all patients respond well to this technique. Since many of the African-American participants in our study reported prior negative experiences during clincial encounters, physicians should consider counseling approaches that let them remain accessible to patients, offering concrete advice on weight loss goals, diet, excercise, and potential ways to address individual barriers.