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There is little qualitative research on the type of weight loss counseling patients prefer from their physicians and whether preferences differ by race.
This qualitative study used semi-structured in-depth interviews of 33 moderately to severely obese white and African-American (AA) women to elucidate and compare their perceptions regarding their primary care physician’s approach to weight loss counseling. Data were analyzed using a grounded theory approach and a series of immersion/crystallization cycles.
White and AA women appeared to internalize weight stigma differently. AA participants spoke about their pride and positive body image, while white women more frequently expressed self-deprecation and feelings of depression. Despite these differences, both groups of women desired similar physician interactions and weight management counseling, including: (1) giving specific weight loss advice and individualized plans for weight management; (2) addressing weight in an empathetic, compassionate, nonjudgmental, and respectful manner; and (3) providing encouragement to foster self-motivation for weight loss.
While both AA and white women desired specific strategies from physicians in weight management, some white women may first need assistance in overcoming their stigma, depression and low self-esteem before attempting weight loss.
Obesity, defined as body mass index [BMI] > 30 kg/m2, affects 36% of the U.S. adult population, with the highest prevalence in African-American (AA) women (58.6%).1 Obesity increases the risk of many chronic illnesses, including heart disease, hypertension, diabetes, stroke, arthritis, and cancer.2
The U.S. Preventive Services Task Force recommends that physicians screen all patients for obesity and offer or refer obese patients to intensive multicomponent behavioral interventions.3, 4 However, many obese patients do not receive an obesity diagnosis or weight related counseling from their physician.5–8 Previous research has identified inadequate physician training, negative attitudes toward obese patients, inadequate reimbursement, and perceived futility of potential conversations as reasons for physicians failing to provide weight related counseling to their patients.5, 6, 9 Little research has explored patient perceptions of physician efforts at addressing weight management.
Cultural differences in attitudes toward obesity among white and AA women may affect their desires and expectations regarding physician interactions and counseling strategies in the management of weight loss. Compared to obese white women, obese AA women tend to under perceive their weight10–13 and have more satisfaction with and acceptance for a larger body size.10, 14, 15 While AA women are more likely than white women to use medically supervised programs,16 and to desire one-on-one counseling with their primary care physician,17 little is known about whether desires for specific physician interactions and counseling differ by race. We sought to elucidate and compare moderately to severely obese white and AA female patients’ desires and expectations regarding their physician’s role in the management of weight loss. An enhanced understanding of the patient’s view will help to foster improved patient-physician interactions regarding weight management.
Data came from semi-structured in-depth interviews of 33 white and AA women, conducted between March 2009 and August 2010 in New Jersey, all of whom were enrolled in a parent qualitative study focusing on barriers to breast and cervical cancer screening among obese women.18 Participants were recruited through flyers placed in community-based organizations, health clinics, and retail establishments. The parent study purposively recruited women between 40 and 74 years old and moderately to severely obese (BMI > 35). To simplify recruitment procedures, a cutoff weight of 220 pounds was also used to establish eligibility. This weight corresponded to the lower limit of moderate obesity (BMI at least 35) for height of 67 inches (90th percentile height in women in a similar sample).19 We excluded women who did not speak English, were pregnant, had a history of breast or cervical cancer, and who did not have an established source of care. All participants received $30 in cash or gift card after completing the interview. The Institutional Review Board of the University of Medicine and Dentistry of New Jersey approved the study protocol, and all women provided informed consent.
Two trained qualitative interviewers conducted interviews by telephone or in-person. Questions for the parent study followed an interview guide that was informed by the Theory of Care-Seeking Behavior20, 21 and modified after pretesting with three focus groups of obese women (N= 18). While the parent study focused on barriers to breast and cervical cancer screening, we also asked questions regarding participants’ healthcare experiences related to weight and their perceptions of physicians’ roles in weight management. These included: “How do you feel about your weight?” “What has your doctor advised you about your weight?” “What have you done to try to lose weight?” “How can doctors better help you to lose weight?” “How has your weight affected your interactions with doctors, nurses, and other staff?” and “What can be done to make getting health care more pleasant for overweight women?” The analytic process included these issues while the study was ongoing.
Interviews lasted 60–90 minutes, and were digitally recorded, transcribed verbatim, and de-identified. Recruitment and interviews continued until data saturation was achieved, i.e., when no new information was emerging. Transcripts were imported into ATLAS.ti (Atlas.ti Scientific Software Development GmbH, Berlin, Germany) for coding and analysis.
We used a grounded theory approach with a series of immersion/crystallization cycles to qualitatively analyze our data.22 In this iterative process, we immersed ourselves in the data through cycles of reading and reflection, recording our insights and emerging themes, until interpretations became evident and crystallized. Initially, we read transcripts together to understand the subject matter and to develop a set of preliminary codes. Joint analysis continued until we agreed on coding schemes. The remaining data were then analyzed individually, with research team members meeting regularly to resolve coding differences and refine coding schemes as needed. All transcripts were independently coded by at least two research team members, and any coding differences were resolved through group consensus. Next, quotes within codes were re-read and analyzed in a second immersion/crystallization cycle, and emerging themes and interpretations were compared and contrasted within and between white and AA women. A third immersion/crystallization cycle was used to refine themes and identify negative or disconfirming evidence for emerging themes. The quotations chosen below best depict and exemplify our key findings.
Table 1 describes our study population of 18 white and 15 AA women. The presentation of our results is organized around four themes that emerged from our analysis.
Cultural differences regarding body image and self-esteem were confirmed in our results. AA women we interviewed spoke more about pride and a positive body-image:
I dress nice. I smell good. And that’s the main thing. But you know it’s your appearance. You know because you a big person –some full-figured women, they don’t care how they look when they walk out. You know when I step out, I want to look good when I step out. Because I am a full-figured woman, so you want to take a little bit of extra care than maybe a skinny person. Because people is going to notice you; they going to look at you and something. You don’t have confidence and you don’t love you, then you don’t care. But when you love you, you know you going to do what you have to do. (Age 45, AA, 350 lbs.)
These participants sometimes attributed their personal self-respect to their family values and upbringing:
My mother was 5’ 5,” and when she died she weighed 250… But Mom always felt that you know what? If I’m not doing nothing to help myself, why get mad if somebody talks about me? And I’ve felt that way. If I’m not trying to lose this weight, why get mad if somebody says something about it? (Age 64, AA, 360 lbs.)
You know I come from a family of full-figured women… my aunties and stuff, they were well-dressed, church-going ladies. And no matter where they go, they could go to the corner store, they always be dressed. (Age 45, AA, 350 lbs.)
Conversely, white participants often described low self-esteem and poor body image concerning their weight:
How do I feel? Depressed, angry, sad, very ashamed. Um… I crack jokes about it, you know, and I say to my friend, “Well, because I’m a fatty, I don’t know if they’re gonna let me on the rides,” or “Because I’m a fatty…” (Age 47, white, 290 lbs.)
I’d like to be able to fit into something. When you get dressed up and you’re a big cow…When I looked at those pictures after the wedding, I looked like a big whale in a mauve dress. (Age 71, white, 265 lbs.)
Despite these cultural differences regarding body image and self-esteem, women’s desires and expectations regarding physician interactions and counseling strategies in the management of weight loss were similar among white and AA participants, as described below in our other themes.
Both AA and white participants expressed a desire for specific advice and personalized weight management plans. When women received generalized and nonspecific weight loss advice from their physician, they equated this with lack of concern, attention, and support. For example:
[They just say] you need to lose weight and you should do it in a healthy way- duh!… They did say something about seeing a nutritionist, but then if you are, as I am, unemployed and I don't have money coming in to see a nutritionist…I'm on my own. (Age 57, white, 220 lbs.)
Subjects mentioned frequent weight monitoring, graphic charting, specific dietary inquiry and recommendations, and providing reference materials and resources, as forms of individualized plans that they wanted from their physician.
Have your chart where they’re graphing your weight… I could go there three times a [week] and get weighed and have my weight on a chart because that will force me to deal with it… It’s drawing your attention to it. If you’re losing, it’s an immediate positive feedback and that gives you the energy to get past the hunger… You do a diet history… you have a doctor checking what you eat all the time so that they can make specific recommendations about your food, that would help. (Age 59, AA, 240 lbs.)
But there's never been any kind of handout that they could say – which might be helpful thing for a doctor's office to say, “You can look at… XYZ on-line.” Or there may be, iVillage or whatever, to give you… a guideline that you could follow. And that, I think would be something that would be helpful for a doctor to have. It would be less threatening... A doctor could say, “I have this information, and you can access it when you're at home or at the library, and these are some sources which could be really supportive.” Right, a guideline, reference materials, resources… there's a lot of people who just don't know how to do it or don't have the handout. And it would be nice if, ideally there was a way to have that handout. (Age 56, white, 228 lbs.)
Both AA and white participants indicated that they were more likely to have favorable weight related interactions with physicians who possessed certain qualities such as being: empathetic, sensitive, respectful, trustworthy, compassionate, non-judgmental, encouraging, honest, and comforting. For example:
I think just to be caring and understanding because being overweight is a disease also and I just think that if they care, show some compassion for people and really go out of their way to try to make them comfortable ‘cause they’re already uncomfortable with the way that they’re, you know, that they feel, they’re already uncomfortable about it. So if they were to show some compassion and caring towards people that are overweight, I think that might be a good thing. That would be helpful. (Age 55, AA, 300lbs)
I think that what would be important is that they listen, because you feel like they don’t listen. And I think instead of grouping us all together, I think if they listened and respected you as an individual instead of lumping fat women together…… You should be more interested in hearing me say, “I’ve tried A, B, C, and D. How do we get to G, F, H, I, J?” So I think they could be more suggestive, more positive in attitude, more patient, more attentive.”(Age 47, white, 290 lbs.)
In addition to tactful communication, participants described the importance of having a positive bedside manner:
Just the tone of their voice. Just have that caring attitude, the approach that they use towards you, you know, that you’re not someone with a plague or something. Just, you know, just to see a caring smiling face sometimes is, you know, is good enough when it comes down to how you approach people so it doesn’t have to be, you know, with an attitude or just being nasty for no reason. People have all kinds of illnesses. Obesity is one of them. (Age 55, AA, 300lbs)
So, you're on the receiving end of factual comments that are – the intonation is disapproving... It's, in most of the cases, it's not what you say, it's how you say it. (Age 56, white, 220 lbs.)
Furthermore, many participants suggested that “sensitivity training” would improve physician and staff interactions with patients not only during a discussion on weight, but across all interactions. For instance:
Specifically, you really need training on how to be polite to their patients. You really need to be educated. (Age 58, white, 228 lbs.)
Educating the doctors… Education, educate the doctors how we feel. Do a video letting them – look, this is the way that we feel. I’m a full-figured woman, but I have feelings. I care. I want you to care. I want you to use common sense, you know and don’t always put it on our weight. (Age 45, AA, 350 lbs.)
AA and white participants agreed that the desire and willingness to lose weight largely depended on self-motivation:
You need to tell yourself. A person who wants to lose weight has to be the one to lose the weight. (Age 66, AA, 250 lbs.)
No, they can’t do it. I have to do it. I have to want to do it. They can’t help me. Nobody can help me. The same thing with smoking. Nobody can stop me until I want to stop. (Age 67, white, 240 lbs.)
However, they noted the need for added encouragement from their physician to help foster their own self-motivation:
At least bring it up once in a while. “How are you doing with it?” I mean, they obviously have me- they weigh the patients every time you go in, and so they’ve got that number. You could comment about it, and even if you had lost a few pounds, say something about it. Try to be encouraging. But at least ask if you need help or if you want help. That in itself would be a big opening. (Age 49, white, 220 lbs)
This is the first qualitative study to examine whether cultural differences in perceptions of weight between obese white and AA women affect their desires and expectations regarding specific physician interactions and counseling strategies in the management of weight loss. While we found cultural differences regarding body image and self-esteem, both white and AA women desired similar physician interactions and weight loss counseling techniques.
Both obese white and AA women recognized that the willingness to lose weight was largely dependent on self-motivation, but they also wanted their physician to foster this motivation by providing encouragement. It has been found that patients with increased levels of self-motivation are more likely to receive higher levels of physician counseling.23, 24 Unfortunately, when compared to the patients themselves, physicians tend to perceive a lower motivation level relating to patients’ desire to lose weight.25 These mismatched perceptions of patient and physician may hinder the supportive interaction our respondents desire. Physicians should be encouraged to provide support to all obese patients and use strategies such as the 5 As framework (Assess risk/current behavior/readiness to change, Advise change of specific behaviors, Agree and collaboratively set goals, Assist in addressing barriers and securing support, Arrange for follow up), as it are associated with higher patient motivation and higher amount of weight loss.23, 24 Very recent changes in Medicare reimbursement guidelines now allow payment for physicians doing intensive weight loss counseling if they document the use of a 5 As approach.26 This policy change has the potential to increase both the willingness of physicians to raise weight issues with their patients and the effectiveness of their efforts using an evidence-based approach to counseling.
Both obese AA and white women desired specific and personalized plans from the physician when addressing weight. Moreover, our study found that when women received generic weight loss advice from their physician, they equated this with lack of concern, attention, and support. Past studies also found that patients prefer an individualized approach rather than having a discussion on the health consequences of obesity.7, 27 Overweight and obese patients who were told of their current weight status and were provided with direct weight loss advice by their physician had more realistic perceptions of their own weight, a desire to lose weight, and a higher likelihood of consuming fewer calories and using exercise to lose weight.6, 28 In an attempt to provide physicians with strategies for the office based management of obesity, it has been suggested that the physician and patient agree on a plan, come up with reasonable goals to change behaviors, and arrange for follow-up of progress.29 Integrating individual patient opinions and desires into recommendations are beneficial; for example, individuals are more likely to adhere to exercise activities when they self-select the activity.30 These approaches are essential elements of counseling incorporating Motivational Interviewing (MI) techniques, which can make weight loss counseling more effective.31 The MI techniques, which are compatible with a 5 As counseling format, emphasize affirming patients’ efforts by eliciting their own personal motivations for losing weight, and tailoring the goal-setting and plans to the patients’ preferences.
Both groups of women also indicated that they were more likely to have favorable interactions when discussing weight with physicians who were empathetic, sensitive, respectful, trustworthy, compassionate, non-judgmental, encouraging, honest, and comforting. Furthermore, many participants in our study directly suggested that “sensitivity training” would improve the physician interactions with patients not only during a discussion on weight, but across all interactions. Past studies have demonstrated that many health professionals hold negative views toward obese patients, characterizing them as lacking self-control, discipline, willpower and/or motivation to lose weight.9, 32, 33 In addition, a higher BMI in patients has been associated with lower respect from the physician toward his or her patient.34 These negative attitudes affect health care delivery as evidenced by health care providers spending less time in appointments and providing less health education with obese patients compared with thinner patients.35, 36 A resource for sensitivity training is “Weight Bias in Health Care,” a 17 minute video produced by Yale Rudd Center for Food Policy and Obesity (available at http://www.yaleruddcenter.org/what_we_do.aspx?id=10). The video challenges existing weight-based stereotypes, attempts to induce empathy towards obese patients, and provides strategies for bias free health care practices. Improving physicians’ attitudes and behaviors toward obese patients may help to enhance patient-provider interactions and foster obese patients’ motivation to lose weight.
It appears that white women in our study internalized weight stigma more than AA women. AA women displayed more self-confidence and positive body image, whereas white participants often expressed low self-esteem and depression concerning their weight. Most participants didn’t use the term, ‘obesity’ when describing themselves. AA women more often used adjectives such as, ‘thick,’ ‘heavy,’ ‘big boned,’ ‘big,’ and ‘fullfigured,’ while some white women referred to themselves as ‘fatty’ and identified themselves using derogatory terms, such as ‘cow,’ ‘whale,’ and ‘elephant.’ Our study identified a possible reason for the difference in self-esteem and body image among obese white and AA women. AA participants mostly attributed their personal self-respect to their family values and identification with other female family members who were overweight or obese. To our knowledge, no research has reported racial differences in internalization of weight stigma. This exploratory study raises this issue as a potential area for further study. While both AA and white women desired specific strategies from physicians in weight management, some white women may first need assistance in overcoming their stigma, depression and low self-esteem before attempting weight loss. For example, teaching mindfulness and acceptance targeting obesity-related stigma and psychological distress has been shown to improve quality of life and weight loss efforts among white women.37 More research is needed to elaborate the differences in perception of weight stigma among white versus AA women and the role this may play when providing weight loss counseling.
This study has limited generalizability. As a qualitative study it was not designed to produce generalizable findings but to probe in-depth into participants’ feelings and perspectives. Although geographically limited to the state of New Jersey, participants were recruited from the community and from diverse backgrounds. Additionally, the age of the subjects were limited to 40–74, but the prevalence of obesity is highest in middle-aged women.1 In addition, this study included only moderate to severely obese women, and women with BMI 21–35 may be more likely to be missed by physicians as needing weight loss counseling.
In summary, we found that both white and AA women desire specific weight loss advice and individualized plans for weight management given by physicians in an empathetic, compassionate, respectful and non-judgmental manner. While white and AA women appeared to internalize weight stigma differently, both groups recognized the need for self-motivation and physician encouragement to successfully lose weight. Understanding these themes will help to foster improved patient-physician interactions regarding weight management.
This study was supported by a research career development award (JMF) from the National Cancer Institute (K07CA101780) and National Service Research Award (AF) from the Department of Health and Human Services Administration (6 T32HP10011). The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Cancer Institute, National Institutes of Health, or the Department of Health and Human Services Administration. The New Jersey Primary Care Research Network (NJPCRN) and The Office of Community Outreach at The Cancer Institute of New Jersey assisted with patient recruitment. We thank Jennifer Hemler for assisting with data coding and Elisa Rossetti for assisting with data collection and coding.
Conflict of Interest: None disclosed.