Attitudes of Medical Professionals toward Obese Individuals
Anti-fat attitudes among health care professionals, if they exist, could potentially affect clinical judgments and deter obese persons from seeking care. A number of studies have addressed this topic. A study of over 400 physicians identified patient characteristics that aroused feelings of discomfort, reluctance, or dislike (40). Physicians were mailed anonymous questionnaires and asked to specify five diagnostic categories and social characteristics of patients to which they responded negatively. One third of the sample listed obesity as one of these conditions, making it the fourth most common category listed (among dozens of other categories), and ranked behind only drug addiction, alcoholism, and mental illness. Physicians associated obesity and other negatively perceived conditions with poor hygiene, noncompliance, hostility, and dishonesty. The authors concluded that physicians’ responses may reflect Protestant ethic values, which emphasize self-discipline, persistence in the face of adversity, and achievement—characteristics that physicians believed were low or absent in patients with conditions like obesity and alcoholism (40). Similarly, a study of 318 family physicians using anonymous questionnaires found that two-thirds reported that their obese patients lacked self-control, and 39% stated that their obese patients were lazy (41).
Another study examined attitudes about obese patients in health care professionals specializing in nutrition (N = 52) and found that 87% believed that obese persons are indulgent, 74% believed that they have family problems, and 32% believed that they lack willpower (42). Furthermore, 88% said that obesity was a form of compensation for lack of love or attention, and 70% attributed the cause to emotional problems.
These negative attitudes are not new. In 1969, Maddox and Liederman (43) addressed fat biases using self-report measures among 100 physicians and student clerks from a medical clinic. Obese patients were viewed as unintelligent, unsuccessful, inactive, and weak-willed. In addition, physicians indicated that they preferred not to treat overweight patients and that they did not expect success when they were responsible for their management.
Some research has also examined perceptions of nurses. A study of 586 nurses investigated beliefs about obesity and found that patient noncompliance was rated as the most likely reason for obese patients’ inability to lose weight (44) and that ineffectiveness of weight loss programs as the least important reason for lack of success. Yet, the nurses reported confidence in giving weight loss advice regardless of the outcome and despite spending 10 minutes or less discussing weight loss with patients.
In a similar study, nurses agreed that obesity can be prevented by self-control (63%) and that obese persons are unsuccessful (24%), overindulgent (43%), lazy (22%), and experience unresolved anger (33%) (45). In addition, 48% of nurses agreed that they felt uncomfortable caring for obese patients, and 31% would prefer not to care for an obese patient at all.
These findings parallel another investigation of women registered nurses (N = 107), where 24% of nurses agreed or strongly agreed that caring for an obese patient repulsed them, and 12% reported that they preferred not to touch an obese patient (46). Older nurses had less favorable attitudes than younger nurses, and dissatisfaction with their own weight was positively correlated with negative stereotypes.
Only two studies have examined attitudes toward obesity among dietitians. One study of 439 registered dietitians showed ambivalent attitudes toward obese clients (47). In contrast, a study examining attitudes among dietetic students (N = 64) and registered dietitians (N = 234) reported negative attitudes toward obesity among both groups (48). This is an important area for further inquiry because dietitians are often in a position to influence patients’ attitudes toward food and eating.
In addition to professionals already working in the medical field, studies have also surveyed medical students regarding their attitudes toward the obese. Blumberg and Mellis (49) reported substantial prejudice by medical students toward obese patients. On characteristics of personality, humanistic qualities, body image, and qualities related to medical management, students rated morbidly obese individuals significantly more negatively than average weight persons, who were rated neutrally or positively. Adjectives thought to apply to obese patients included worthless, unpleasant, bad, ugly, awkward, unsuccessful, and lacking self-control (49). Negative attitudes did not change after students worked directly with obese patients during an 8-week psychiatry rotation. These results support other research documenting stigma and stereotyping among students (50) (51).
The most recent study on practices of health professionals queried obese individuals in treatment about their experiences with physicians. The subjects were generally satisfied with their care for general health issues and their physicians’ medical expertise. They were, however, significantly less satisfied with the care they received for their obesity. Nearly one-half reported that their physicians had not recommended common methods for weight loss, and 75% reported that they look to their physicians a “slight amount” or “not at all” for help with weight (52).
Only one study has attempted to intervene by reducing stigma toward obese patients, this among medical students (53). Before random assignment to a control group or education intervention involving videos, written materials, and role playing exercises, the majority of medical students in this study (N = 75) characterized obese individuals as lazy (57%), sloppy (52%), and lacking in self-control (62%), despite indicating an accurate scientific understanding of the cause of obesity. After the educational course, students demonstrated significantly improved attitudes and beliefs about obesity compared with the control group. The effectiveness of the intervention was still supported 1 year later.
Implications of Prejudice for Health Care of Obese Persons
It is important to address the impact of negative professional attitudes on clinical judgment, diagnosis, and care for obese individuals. Several studies have indicated that obesity may influence judgments and practices of professionals. Young and Powell (54) assessed clinical judgments among mental health workers using an analog approach in which participants evaluated a case history of a patient in one of three weight conditions. The obese patient was most frequently assigned negative symptoms compared with the overweight and average weight clients and was rated more severely on a variety of dimensions of psychological functioning (54).
A more recent investigation of over 1200 physicians (representing specialties of family practice, internal medicine, gynecology, endocrinology, cardiology, and orthopedics) indicated poor obesity management practices (55). Physicians completed self-report surveys addressing attitudes, intervention approaches, and referral practices for obese patients. Although physicians recognized the health risks of obesity and perceived many of their patients to be overweight, they did not intervene as much as they should, were ambivalent about how to manage obese clients, and were unlikely to formally refer a client to a weight loss program. Only 18% reported that they would discuss weight management with overweight patients, which increased to 42% for mildly obese patients.
Similar results were reported by Price et al. (41). Among 318 physicians surveyed, many referred obese patients to commercial weight loss programs with questionable success. Although the majority felt obligated to treat their obese patients, 23% did not recommend treatment to any of their obese patients and 47% said that counseling patients about weight loss was inconvenient (41).
Another study suggests that physicians may be ambivalent in treating obesity. In a sample of 211 primary care physicians, only 33% reported being centrally responsible for managing their patient's obesity, where 39% perceived their role to be cooperative to other providers (56). Although attitudes were not reported in this study, physicians indicated that insufficient time, lack of medical training, and problems of reimbursement were difficulties in managing obesity effectively.
A final study surveying attitudes and practices of 752 general practitioners in weight management reported mixed results (57). These physicians reported holding positive views about their roles in obesity management but underused practices that promote lifestyle changes in patients, described weight management as professionally unrewarding, and noted their most common frustrations in treating obesity were perceptions of poor patient compliance and motivation.
Negative attitudes and reluctance in physicians may lead obese persons to hesitate to seek health care (58), although as we mention below, other factors may also contribute. In one study of physician and patient behaviors, 290 women and over 1300 physicians responded to anonymous questionnaires to determine the influence of obesity on the frequency of pelvic examinations (59). Reluctance to have examinations increased from average weight to moderately overweight to very overweight women, where the very overweight women were significantly less likely to report annual pelvic examinations. Body image was associated with pelvic exams; 69% of women who had a positive body image vs. 55% of those who had negative body image reported obtaining examinations. Among physicians, 17% reported reluctance in providing pelvic exams to very obese women, and 83% indicated reluctance when patients were reluctant themselves. The youngest physicians were most reluctant to perform pelvic exams, and among the oldest physicians a gender difference emerged where men physicians were more reluctant to provide exams than women physicians. Considering that overweight women feel hesitant to obtain exams because of their negative body image and that physicians are reluctant to perform exams on obese or reluctant women, many overweight women may not receive necessary treatment (59).
Two other studies have documented delay in seeking medical care by obese women. One investigation of self-reports of 310 hospital-employed women (such as nurses and nursing assistants) found that body mass index (BMI) was significantly related to appointment cancellations (60). Over 12% of women indicated that they delayed or canceled physician appointments due to weight concerns, and of the 33% of women who had discussed weight with their physicians, discussions were described as negative (60). In addition, 32% of women with a BMI > 27 kg/m2, and 55% of those with a BMI over 35 kg/m2 delayed or canceled visits because they knew they would be weighed; the most common response for delaying appointments was embarrassment about weight (60).
Another recent self-report study of women (N = 6891) included in the 1992 National Health Interview Survey reported that increased BMI was associated with decreased preventive health care services (61). Obese women were significantly more likely than non-obese women to delay breast examinations, gynecologic examinations, and papanicoloau smears, despite an increase in physician visits as BMI increased. The authors concluded that even when obese women have more frequent physician appointments, they seem least likely to use preventive services (61).
Most available studies have assessed physician attitudes and beliefs, which may or may not affect their practice, and, other health care professionals have not been studied in detail. Research has failed to account for the fact that obese patients may delay or cancel medical appointments for a variety of reasons, such as anxiety about being weighed or disrobing regardless of how supportive health care professionals may be. Still, it is clear that health professionals share general cultural anti-fat attitudes. Considering that bias affects many of the ways individuals interact with stigmatized groups, it would be surprising if medical practices were immune.
The hope is that care for obese individuals will improve as bias decreases. Some health care professionals perceive obesity to be a social problem and systematically avoid it in their practices (62). For those who consent to treat obese patients, removing prejudice and blame may be crucial. As Yanovski (63) notes, “The primary care physician who provides sensitive and compassionate care for severely obese patients without denigrating them for their inability to lose weight performs a much needed service.” Other suggested changes include recognition of obesity as a chronic medical condition, improved knowledge of nutrition and multidisciplinary treatments, familiarity with community resources, creating more accessible environments for obese persons by providing armless chairs and larger examination gowns, and treating patients with respect and support (63) (64).