Addressing Obesity: How Do Practitioner Views Impact Care?

For patients with obesity, medical management is key to staving off negative health outcomes and related comorbidities, including diabetes, cardiovascular disease, hypertension, and more. However, healthcare practitioners’ (HCP) perceptions about weight, as well as the presence of obesity bias, can hinder patients’ paths to proper treatment.

Does Obesity Bias Influence Medical Decision-Making?

"The growing prevalence of obesity has brought to light the discussion on the challenges that people living with it face in society and more importantly in health services," Heiden Telo and colleagues explained. "In recent years, evidence has grown on events in which patients with obesity were targets of derogatory attitudes in healthcare environments. Often described as ’weight stigma,’ these attitudes reflect negative beliefs towards individuals with obesity, including the unfounded conviction that they are ’lazy’ or ’non-adherent to treatment.’

"The origins of the phenomenon that lead to different behaviors according to the individual’s weight are still not fully understood," they continued. "One of the mechanisms potentially implicated is cognitive bias, also known in this scenario as ’obesity bias.’ Cognitive biases are defined as associations that occur instinctively and represent an unconscious mental shortcut created based on previous experiences, personal beliefs, and other non-identified factors. While obesity bias differs from prejudice itself, both conditions are synergic to each other. Contrary to prejudice, obesity bias is often an unconscious process, called implicit bias, and for that reason becomes an underestimated and undervalued problem. Explicit bias, on the other hand, refers to actions or thoughts that are intentional and operate at a conscious level. The negative label of obesity as an aesthetic characteristic rather than a disease is not only common but also a consequence of this bias. This type of stigma may drive not only patients away from medical appointments but also affect physician’s clinical thinking and decision-making processes."

While awareness of obesity bias has been increasing, most reviews on the subject focus on patient perspectives and reports on health professionals’ attitudes. Few studies, however, have directly assessed how cognitive biases influence HCPs’ therapeutic decisions when treating patients with obesity. To better understand how these biases influence care, Heiden Telo and colleagues conducted a review to synthesize existing studies and outline how the presence of obesity can impact decision-making and medical conduct in healthcare.

Their systematic review included observational studies published from 1993 through 2023. The primary outcome was the difference between clinical decisions in the treatment of individuals with versus without obesity.

Among the findings:

• In 696 million office-based physician visits (2005-2006), when looking at patients with clinical obesity (BMI≥30 kg/m²), "a significant percentage of 70% (95% CI, 61-79%) went undiagnosed, while 63% (95% CI, 59-68%) received no counseling regarding diet, exercise, or weight reduction." Lack of height and weight measurements were associated with poorer performance.
• In a study from Denmark investigating differences in treatment for episodic tension-type headaches based on weight status and gender, "[s]ignificant differences were observed in explicit negative attitudes towards individuals with obesity (mean=4.59; 1=Very positive to 7=Very negative), which were notably stronger compared with attitudes towards people of normal weight (mean=3.26; P<0.001). [General practitioners] GPs also demonstrated explicit stereotypes, perceiving individuals with obesity as lazier (mean=4.44; 1=Very motivated to 7=Very lazy) in contrast to those with normal weight (mean=3.87; P<0.001), but their decisions regarding the treatment of patients with obesity and patients with normal weight through medication and/or non-medical therapy did not differ."
• Patients with obesity were less likely than patients in other weight groups to receive screening for colorectal cancer, and in an analysis by Rosen et al, this association was particularly significant among women with obesity.
• Women with obesity were significantly less likely to undergo Pap smears or mammography screening than women in other weight categories—the study authors highlighted the lower rates of mammography screening in particular, as women with obesity are more likely to develop breast cancer.
• Patients with type 2 diabetes and obesity were less likely to receive pharmacological treatment intensification than non-obese patients (53.7% versus 67.4%, respectively; P=0.05). Conversely, patients with obesity and depression were more likely to receive an antidepressant prescription compared with "normal-weight" patients, despite the "known obesogenic properties" of many antidepressant drugs. Patients with obesity were also more likely to receive 3 or more antidepressants, though it is not clear whether these finding reflect "a more severe form of depression" among patients with obesity or the attitudes and beliefs of their health care providers.

The study authors concluded that their systematic review "confirms that obesity bias compromises not only medical consultations but also additional procedures and treatments, predominantly in preventive screening exams. On that matter, women seem to be a particularly vulnerable group; with less Papanicolaou smears, colorectal cancer screening tests and mammography tests. The quality of medical consultations also seems to be harmed by obesity bias; with less eye contact between parts, less confidence in the patient’s ability to comply with treatments, and lower performance of specific physical examinations and measurements."

Unpacking HCP Perceptions of Obesity

While it is important to understand the impact that HCP perceptions can have on treatment for patients with obesity, it is equally important to understand what those perceptions are in order to better address them and improve outcomes in this patient population. To that end, Laura Jeffers, of the Scottish Collaboration for Public Health Research and Policy at the School of Health in Social Science, University of Edinburgh in the U.K., and colleagues conducted a systematic review designed to aid in understanding the perceptions of HCPs towards overweight and obesity and weight management; the experiences of developing and maintaining a therapeutic relationship when discussing weight and weight management with patients; and the resources needed to develop that therapeutic relationship.

Their findings were published in Primary Health Care Research & Development.

For their review, Jeffers and colleagues looked at qualitative research involving focus groups or interviews (with semi-structured or open questions) assessing the experiences, perceptions, and attitudes of HCPs in the provision of weight management services among patients with overweight or obesity. A total of 15 papers were ultimately included in their review.

From these papers, Jeffers and colleagues identified four themes that influenced HCP’s approach to managing obesity in their practice: 1) conflicting discourses surrounding obesity; 2) medicalization of obesity; 3) organizational factors; and 4) lack of patient knowledge and motivation. The study authors broke down these themes as follows:

1. Conflicting discourses surrounding obesity: Twelve papers reported "conflicting ideas as to whether wider social, cultural, and psychological factors in addition to physical factors affect weight." For example, while some practitioners perceived weight loss as a matter of "eating less and doing more," others saw societal, cultural, and psychological factors as playing a role. Conflicting approaches to weight stigma were also seen—some papers reported practitioner awareness of weight stigma, with some practitioners noting that they did not want to judge or offend their patients out of fear of compromising the therapeutic relationship; conversely, some practitioners actively enforced stigmatization, referring to overweight patients as "lazy" and less likely to care about their health. In contrast to stigmatization, there was also evidence of some practitioners normalizing being overweight, or downplaying the consequences. Some practitioners also cited their own weight as a factor in their assessment of obesity—some practitioners with higher BMIs felt that they were not able to give weight advice or felt hypocritical, and some cited weight stigma directed at themselves by patients; on the other hand, practitioners with lower BMIs expressed feeling "preachy," and that patients thought they did not understand what it was like to be overweight.
2. Medicalization of obesity: Eight papers expressed perceptions of the "non-medicalization" of obesity; practitioners reported that they don’t deal with obesity itself but rather address associated comorbidities, and some said that they would "never" bring up weight unless patients referred to it themselves. Practitioners also demonstrated a tendency towards non-medicalization of obesity "by focusing on weight loss, healthy eating and exercise in an effort to avoid labeling patients instead of using the words ’obese’ and ’obesity.’ Additionally, two HCPs felt discussing weight was inappropriate due to wider social, psychological and cultural factors affecting a person’s weight." Alternatively, a handful of papers identified positive reasons to address the topic of weight with overweight patients, even if they were not deemed unhealthy. This reflected agreement with medicalization of obesity, "where being overweight with no other comorbidities is enough to merit weight loss advice."
3. Organizational factors: Practitioners expressed "a lack of knowledge to give sufficient weight loss advice, a lack of resources available and an absence of multidisciplinary approaches. Lastly, many acknowledged the sensitivity of the topic and stated they did not have time for a thorough conversation surrounding weight."
4. Lack of patient knowledge and motivation: Practitioners felt that patients required knowledge surrounding healthy diets in order for them to effectively manage their weight. Practitioners also suggested that patients who did not want advice wished for "easy" ways to lose weight and were not aware that people rarely comply with restrictive diets; therefore, practitioners felt a responsibility to educate patients to successfully make positive lifestyle changes." Some practitioners also noted that patients need to motivate themselves to lose weight, not just receive motivation from their doctor.

"Managing obesity and changing practice in this climate is extremely challenging," Jeffers and colleagues concluded. "However, arguably managing weight may be an increasingly imminent issue as inequalities within society and within health have widened since the pandemic, thus whilst challenging, public health initiatives are required. The argument could therefore be made that it is important these conversations between HCPs and patients take place to prevent exacerbation of the obesity crisis in the future."

Based on their findings, Jeffers et al outlined key action points for how practice, policy, and research can apply the information in this review:

• "Further research is required to increase understanding of the influence of societal weight norms on the therapeutic relationship between HCPs and patients in primary care.
• "This research and future research should be used to guide the development of resources and training which will facilitate positive weight management conversations.
• "Positive research results should be used to develop a standardized guideline to reduce the variability in weight management care provided by HCPs.
• "A multidisciplinary approach must be applied to manage the vast range of factors that affect weight.
• "Improved therapeutic relationships and reduced stigma between patients and HCPs will lead to increased engagement in weight management and a reduction in overweight/ obesity."

Heiden Telo et al had no relevant relationships to disclose.

Jeffers et al had no relevant relationships to disclose.

Heiden Telo G, et al "Obesity bias: How can this underestimated problem affect medical decisions in healthcare? A systematic review" Obes Rev 2024; DOI: 10.1111/obr.13696.

Jeffers L, et al "Healthcare professionals’ perceptions and experiences of obesity and overweight and its management in primary care settings: A qualitative systematic review" Prim Health Care Res Dev 2024; DOI: 10.1017/S1463423623000683.