Attitudes of Health Professionals to Overweight and Obese People
BODY IMAGE RESEARCH SUMMARY
Attitudes of Health Professionals to Overweight and Obese People
(Bron : http://www.internationalnodietday.com/Documents/RS%20Health%20Profs-ed.doc)
Terrill Bruere (Dietitian, Royal
Women's Hospital, Melbourne) and
Thea O'Connor (Dietitian, Director Body Image and Health Inc)
Attitudes to the Obese
Society and the negative stereotype
Throughout history there have been stereotypes based on large body size, both positive (particularly in times of food scarcity, reflecting ideas of abundance, fecundity and wealth) and negative (often when societies are advancing socially and food is plentiful, reflecting sloth, gluttony and poor willpower). The negative stereotype of the overweight and obese has been with us a long time and can be traced back through history to pre-Christian times of Greek philosophy (1).
Currently society holds a negative picture of overweight people that even young children are familiar with. Characteristics such as lazy, stupid, sad, ugly, lacking willpower, or awkward are attributed simply on the basis of body shape and size. It is a view found to varying degrees across gender, race and age (2).
The other side of this coin is the association in the media and fashion industries of thinness with desirable characteristics such as happiness, youth, acceptance, self-confidence and meaningful romance (4). This reinforces the perception that overweight people are not these things, but that they can be obtained by losing weight. Overweight people stigmatised in this way do indeed tend to do less well in school, are less likely to enter some professions, and have been shown to earn less than thinner women and less than those with other chronic health problems (5). Focus group discussions reported by Murphree (6) show the overweight feel penalised for their size due to experiences of derogatory remarks, job discrimination, and a lack of fashion and furniture design for them.
The belief that weight is under primarily personal control and can be relatively easily changed at will is very strong and probably contributes to the continuing view of larger people being weak willed or lazy. Recent research of 1330 Victorian rural adults showed that most people believed weight was under personal control, with external factors such as chance, fate or environment being less important (7). More than half believed that weight gain was the consequence of the individual's behaviour and that unsuccessful dieting was due to a lack of effort. Almost half believed that the overweight lacked willpower, although 1/3 did disagree with this. The belief that the individual was to blame was stronger in men than women, as was the belief that dieters needed to be 'pushed' rather than 'supported' to lose weight. These beliefs suggest that being overweight is seen as being due to an individual character flaw. The role of genetics, metabolism and the difficulties of managing a less healthy environment (with inadequate physical exercise and plenty of cheap, higher energy foods) are not as generally recognised (4), but even when they are, negative attitudes persist.
Health professionals and the
The helping and caring aspects of health professionals' work would perhaps be expected to lead to less bias. However a number of studies show that negative views of overweight people persist beyond training into professional life. Price et al. (8) looked at 318 American GP's attitudes to larger patients and found that 66% believed larger people lacked self control, 39% thought they were lazy, and 34% believed the overweight were sad. Research by Cade and O'Connell (9) found a similar response amongst English GP's. Maiman et al (10) looked at 52 'nutritionists' and found that 84% agreed that overweight people were self indulgent, 88% believed overweight people ate to compensate for other problems, 70% assumed they were emotionally disturbed and 33% believed they lacked willpower. Young and Powell (3) examined 120 mental health professionals and found that when shown photographs of normal weight, overweight and obese clients, they evaluated the larger clients more negatively than the others.
Society may initially teach health professionals these ideas about the overweight but there are reasons why they persist. One factor is the current treatment paradigm that underpins health professionals' work with weight reduction and its potential to reinforce and maintain the negative stereotype when weight loss fails. Health professionals have mixed feelings about this area of their work, which can affect both their views of their clients and of themselves.
Attitudes To Treatment of Obesity
- Why Ambivalence to Treatment And to the Obese Client?
The pressure to treat weight issues
There is increasing pressure on professionals to achieve successful weight management for health reasons. The incidence of coronary heart disease, osteoarthritis, diabetes, stress and some forms of cancer are all on the rise and the importance of weight management in the treatment and prevention of these 'lifestyle' illnesses is well accepted and supported by health professionals (4)(8)(9)(11).
Over half of Australians are now considered overweight and one in five obese (7). About 70 % of people will visit a local doctor in a year, which means that the GP sees a significant proportion of the overweight population and therefore has the opportunity to develop long-term relationships and regular contact with these people. This provides both treatment and prevention possibilities for weight management (9)(12), particularly as the GP's advice is also perceived as powerful and influential (8). Other disciplines involved in health education such as nurses and dietitians also feel this obligation to treat (5) (11) (18).
How the professional feels about providing treatment
The attitude of the GP and other
health professionals to treating the overweight is not always
positive. Cade and O'Connell (9) demonstrated that GP's believed
that they were less effective than both family and the media in
persuading patients to lose weight and most did not find the work
easy or professionally rewarding. Similarly Price et al (8) found
47% of GP's did not believe counselling the obese was professionally
gratifying. Only 29% believed
these people could achieve significant weight loss and 37% believed the formerly obese could not maintain weight loss. This is despite 63% believing they were competent in prescribing weight loss.
A recent survey of dietitians showed that only a third believed they were effective in weight management and only a third considered this area to be professionally rewarding (5). This again is in spite of a strong belief in their role in the treatment of obesity. Hoppe and Ogden (11) also showed that in spite of being confident about giving advice in primary care GP practice nurses, they were not optimistic about outcome. Other studies support this finding that both health professionals and their patients are ambivalent about obesity treatment and pessimistic about long-term success (10,13).
Who is at fault when weight loss fails?
The long-term success rate of weight loss advice and programs is very low (14,16) and it is often the patients who are held responsible for this poor outcome. This blaming of patients is cited by Himmel et al. (12) as being a possible defence mechanism for the GP to cope with their disappointment and frustration at being unable to produce weight loss. The nurses Hoppe (11) looked at also understood failed attempts at weight loss in terms of patient factors such as non-compliance and poor motivation. This then allowed them to maintain their own view of themselves as providing good advice and being professionally competent. The effect however of labelling the patient in this way reinforced the negative view of the overweight patient and the outcome of treatment. Conversely the other reaction can be the health professional questioning their own competency to treat, leading again to mixed feelings about their dealings with these patients. When discussing success in management, Wooley and Garner (15) note that 'whatever negative attitudes the health professionals bring to counselling, they are intensified as the professionals fail to achieve the allegedly attainable therapeutic goals, leading them to question their own competency.'
The Body Mass Index as a measure of success and its role in the experience of failure
When the Body Mass Index (B.M.I.) is used as the gauge of success it can lead to setting unrealistic weight goals and the subsequent experience of failure for both the health professional and patient. For example, the likelihood of an 'obese' person achieving an "ideal" B.M.I. within the "healthy weight range", is usually low. The effort of staying there if it is achieved is then unable to be maintained by many and the effect on self-esteem and long-term emotional health of trying to do so, can be damaging (4,16).
A different paradigm for weight management, which focuses on an individual's overall health and lifestyle rather than primarily on weight loss, is discussed in the position paper of the American Dietetic Association on weight management (16) and by Hawks et al (4). Redefining success to include more realistic weight goals, which is a critical aspect of this new paradigm, has the potential of not only improving health but also the experience of both the health professional and the client.
The treatments offered
Each time that an overweight person is counselled they are likely to receive similar advice and information, hence most do in fact know what they 'should' do (17). Reiterating advice to eat less and exercise more maintains and reinforces the unfounded belief that weight loss is simple and that overweight people always eat more, exercise less, and have poor willpower (5,15).
Professional Factors which Influence Attitudes
Work related factors
The practical issues of time constraints and lack of financial reimbursement can also add to the difficulties health professionals have in providing weight management services. This can contribute further to the ambivalence they feel about treating overweight people, which then affects their attitudes to overweight clients and their problems(13,5).
Education and professional experience
Education, knowledge about discrimination and age have not been shown to alter practitioner attitudes and practices. Professionals often feel underskilled in the area of weight management and agree that they want further training, knowledge and skills (9,17) - but will this help improve attitudes?
Oberrieder (18), when examining the dietetic profession, suggests that work experience and training do not necessarily improve attitudes to overweight clients as there was no difference between the attitudes of students and experienced dietitians. Maiman (10) hypothesises that attitudes to obesity are a response to societal evaluations of obesity rather than due to knowledge and skills acquired through professional education. Weise (19) shows that accurate knowledge in medical students does not reduce negative attitudes to overweight people but educational interventions aimed at attitude change can, and this change can be sustained.
Personal experience - a tool for attitude change
Research shows that the most
important factor leading to better attitudes toward overweight
patients amongst health professionals is a personal or family
experience of weight problems. This was demonstrated in dietitians
by both Maiman (10) and Oberrieder (18). Those who perceived themselves
as overweight, whether or not they were, were more likely to be
sympathetic to their overweight clients. Those who were at a 'healthy'
weight were more likely to hold negative ideas about overweight
clients. Maiman proposes therefore that more direct and personal
experiences can result in more positive views of the obese - an
important observation for the future education of professionals.
Ogden and Hoppe (20) discuss the differences between a 'learner
centered' model of education (leading to a more patient centered
approach to counselling), and more traditional education. It appears
that the learner centered approach, using personal reflection
and problem solving, offers more scope for the health professional
to learn from the clients experience about being overweight, than
the traditional approach, but it can be time consuming. This,
together with the findings of
Breytspraak (21) and Weise (19), suggest that students trained in more self-reflective ways may have a better chance of learning about and questioning their own attitudes, allowing gradual, ongoing change.
Do Negative Attitudes Affect the Counselling Process and How?
There is less information about this but available research indicates it is a problem. Wooley and Garner (15) point out that the helplessness the health professional experiences in treating obesity has lead to some 'extraordinary therapeutic stances'. 'Authoritarianism, shaming, fear, childlike reward and punishment may be used in frustration. The patients' views may also be discredited as evidence of their inability to 'face the truth' about themselves. The actual experiences of the obese may be overlooked or discounted if they do not fit the therapists' ideas and this can erode confidence and self trust. When the obese do feel safe to express their feelings they talk of deep humiliation in therapeutic relationships' (15).
Hoppe (11) examined this issue
in his study of London nurses by looking at how variations in
beliefs influence decisions about treatment. The nurses who had
a personal experience of being overweight or who worked solely
in weight management, were likely to not only have a more sympathetic
and client centred attitude but also gave different and broader
advice than those without this experience.
Breytspraak et al (21) presented 103 medical students with a videotape or audiotape of a patient dressed as normal weight or overweight. The 'overweight' patients need for treatment and their personal characteristics were assessed differently to the 'normal' weight patients. This is similar to other patient groups where treatment and assessment has been shown to be influenced by information given to the health professionals about psychiatric history, social class and client attractiveness. Breytspraak's video exercise was also used for feedback and training of the students and was felt to be a valuable way of illustrating how bias can alter an interview process.
Agell and Rothblum (22) investigated psychologists and found differences in how obese clients were perceived but found no effect of this on therapy recommendations.
Other research shows that obese women are less likely than nonobese women to undergo pap smears or breast examinations (23, 24, 25). This may be accounted for, at least in part, by the obese women's fear of health professionals' negative attitudes towards their size(23,24)
There is limited research on how the clients themselves experience the stigma attached to their bodies but the indications are that they would like a new approach to their bodies, themselves and their weight issues (6, 23).
There is a strong continuing
belief in the negative character flaws of larger people amongst
different health professional groups. Personal experience is consistently
the most influential factor in changing these attitudes, which
suggests a more self-reflective style of education for health
professionals might help shape better attitudes. The effect of
the negative stereotype on the therapeutic relationship seems
to be significant. The health professional who wishes to help
but can become trapped by their own understanding of weight and
its treatment into a
cycle which limits their job satisfaction, sense of competency and client respect. Add to this the limits to time, training and resources in the medical system and their reluctance to treat overweight and obesity is understandable. Both the health professional and the client are struggling with a complex issue that is not easily resolved in their search for better weight management and health. Shifting the focus to the broader issues and changing treatment paradigms may break the cycles of advice and failure, opening the way for new, joint solutions. Ultimately experience and education about the stigma of obesity at all ages is needed to change these ancient attitudes.
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