Er is al heel wat onderzoek gedaan naar gewichtsdiscriminatie in de zorgsector. Telkens opnieuw blijkt dat dit een reëel probleem is en geen uitzondering van hier en daar eens een dikke patiënt.
Vooroordelen over dikke patiënten
Zorgverleners (waaronder huisartsen, verpleegkundigen, diëtisten en artsen in opleiding) denken negatief over dikke patiënten, zowel impliciet als expliciet. Ze zien hen als lui, slordig en ongedisciplineerd. Ze denken dat dikke patiënten minder goed hun adviezen opvolgen en dat ‘obesitas’ voornamelijk een gedragsprobleem is dat veroorzaakt wordt door te weinig bewegen en te veel eten.
Die vooroordelen kunnen een impact hebben op de manier waarop zorgverleners omgaan met hun dikke patiënten. In vergelijking met dunne patiënten kunnen ze bijvoorbeeld anders communiceren, minder informatie geven en minder tijd doorbrengen met hun dikke patiënt. Ze kennen soms ook te veel symptomen toe aan het gewicht, waardoor ze dikke patiënten niet doorsturen voor aanvullende tests of enkel gewichtsverlies adviseren als oplossing.
Negatieve gevolgen voor de patiënt
Wanneer patiënten voelen of vermoeden dat ze gestigmatiseerd worden, zorgt dat voor heel wat stress. Tijdens een doktersbezoek kan dat ertoe leiden dat ze minder effectief kunnen communiceren en dat ze zich terugtrekken uit de conversatie, waardoor ze zich instructies van de arts niet goed herinneren.
Een ander belangrijk gevolg is dat dikke patiënten een doktersbezoek voor lange tijd uitstellen. Dat gebeurt om verschillende redenen, bijvoorbeeld omdat ze zonder respect behandeld worden door de zorgverleners, omdat ze ongevraagd advies gaan krijgen over afvallen en omdat ze zich schamen om gewogen te worden. Dikke mensen gaan daardoor soms pas naar de dokter wanneer hun probleem al vergevorderd is en moeilijker te behandelen.
Gewichtsdiscriminatie in de gezondheidszorg heeft dus heel wat gevolgen voor de gezondheid van dikke patiënten en gaat veel verder dan een opmerking over hun gewicht.
Hieronder vind je een overzicht van onderzoeken die uitgevoerd zijn over dit onderwerp:
“Even professionals whose careers emphasize research or the clinical management of obesity show very strong weight bias, indicating pervasive and powerful stigma. Understanding the extent of anti‐fat bias and the personal characteristics associated with it will aid in developing intervention strategies to ameliorate these damaging attitudes.”
“Even health care specialists have strong negative associations toward obese persons, indicating the pervasiveness of the stigma toward obesity. Notwithstanding, there appears to be a buffering factor, perhaps related to their experience in caring for obese patients, which reduces the bias.”
“Primary care physicians view obesity as largely a behavioral problem and share our broader society’s negative stereotypes about the personal attributes of obese persons. Practitioners are realistic about treatment outcomes but view obesity treatment as less effective than treatment of most other chronic conditions.”
“In this study, patients with higher BMI were less likely to be perceived as adherent to medications by their providers. Physician perception of medication adherence has been shown to affect prescribing patterns in other studies. More work is needed to understand how this perception may affect the care of patients with obesity.”
“Moderately and extremely overweight people were perceived as having reduced self-esteem, sexual attractiveness and health, and to be moderately responsible for changing their situation (but less so than smokers). There were clear level effects in the perceptions of overweight, but not so for smokers. Of the four groups, moderately overweight people were viewed most positively and extremely overweight (obese) people were viewed least positively.”
“Weight bias is commonly observed by students in health disciplines, who themselves report frustrations and stereotypes about treating patients with obesity. These findings contribute new knowledge about weight bias among students and provide several targets for medical training and education.”
“Participants exhibited significant implicit and explicit anti‐fat/pro‐thin bias. Positivity of professional experience with obesity, but not type of professional experience, was correlated with lower explicit anti‐fat bias. Compared to 2001, the 2013 sample had lower levels of implicit bias and higher levels of explicit bias.”
“A majority of students exhibited implicit (74%) and explicit (67%) weight bias. Implicit weight bias scores were comparable to reported bias against racial minorities. Explicit attitudes were more negative toward obese people than toward racial minorities, gays, lesbians, and poor people. In multivariate regression models, implicit and explicit weight bias was predicted by lower BMI, male sex, and non‐Black race. Either implicit or explicit bias was also predicted by age, SES, country of birth, and specialty choice.”
“Analyses revealed more negative stereotyping, less anticipated patient adherence, worse perceived health, more responsibility attributed for potentially weight-related presenting complaints and less visual contact directed toward the obese version of a virtual patient than the non-obese version of the patient. In contrast, there was no clear evidence of bias in clinical recommendations made for the patient’s care.”
“Participants in all conditions expressed a moderate amount of fat phobia and students rated obese patients as being less likely to comply with treatment recommendations compared with non-obese patients. Results from multivariate analysis of variance tests showed students also evaluated obese patients’ diet quality and health status to be poorer than non-obese patients, despite equivalent nutritional and health information across weight categories for each sex in patient profiles. In contrast, obese and non-obese patients were rated to be similarly motivated, receptive, and successful in treatment.”
“Stigma and discrimination toward obese persons are pervasive and pose numerous consequences for their psychological and physical health. Despite decades of science documenting weight stigma, its public health implications are widely ignored. Instead, obese persons are blamed for their weight, with common perceptions that weight stigmatization is justifiable and may motivate individuals to adopt healthier behaviors.”
“Results of this study show that both registered nurses and student nurses have negative perceptions of obesity and are unlikely to attribute positive characteristics to obese individuals. That registered nurses hold more negative attitudes towards obese person is cause for concern.”
“The US nurses were more empathetic, less impatient, and less likely to be repulsed when caring for an obese patient. However, both groups of nurses felt uncomfortable when caring for an obese patient. They reported it physically exhausting and psychologically stressful. And a majority of both groups held negative stereotypic attitudes toward the obese. In-service education programs in which review is undertaken of the causes, consequences, and treatment of obesity might reduce some of this stigmatization.”
“The students’ reactions toward the moderately obese were neutral or negative; while their reactions to the morbidly obese were almost uniformly negative. This is in contrast to their reactions to persons of average weight, which were neutral or positive. The negative prejudices expressed toward the morbidly obese extended beyond characteristics attributed to weight. Their negative feelings towards the obese did not change after direct contact with morbidly obese patients.”
“We conclude that strong implicit and explicit anti-fat bias is as pervasive among MDs as it is among the general public. An important area for future research is to investigate the association between providers’ implicit and explicit attitudes about weight, patient reports of weight discrimination in health care, and quality of care delivered to overweight patients.”
“Our findings raise the concern that low levels of emotional rapport in primary care visits with overweight and obese patients may weaken the patient–physician relationship, diminish patients’ adherence to recommendations, and decrease the effectiveness of behavior change counseling.”
“The weight of a patient significantly affected how physicians viewed and treated them. Although physicians prescribed more tests for heavier patients, they simultaneously indicated that they would spend less time with them, and viewed them significantly more negatively on 12 of the 13 indices.”
“We found that higher patient BMI was associated with lower physician respect. Further research is needed to understand if lower physician respect for patients with higher BMI adversely affects the quality of care.”
“Obesity was not significantly associated with the length of the visit, but influenced what happened during the visit. Physicians spent less time educating obese patients about their health and more time discussing exercise. Obesity was not related to discussions regarding nutrition. Physicians spent a greater portion of the visit on technical tasks when the patient was obese. Mean pre-visit general satisfaction for obese patients was significantly lower than for non-obese patients; however there was no difference in post-visit patient satisfaction.”
“Students indicated as their first response, and with nearly total agreement in every group, that morbidly obese patients were the most common target of derogatory humor by attendings, residents, and students, and that this occurred most frequently in surgery and obstetrics–gynecology.”
“Overweight and obese women were less likely to be screened for cervical and breast cancer with Pap smears and mammography, even after adjustment for other known barriers to care.”
“Emergency physicians frequently underdose cefepime, cefazolin, and ciprofloxacin in obese patients. Underdosing antimicrobials presents risk of treatment failure and may promote antimicrobial resistance. Education is necessary to improve early antibiotic administration to obese patients.”
“We found the expected biases toward patients when in their obese form as well as pessimism about patient compliance and success of therapy, but there were no significant differences in tests or treatments ordered except where appropriate for an obese patient (e.g., weight reduction diet). Thus, the appearance of obesity alone biased the students’ impressions of the patients, but did not affect diagnostic test ordering.”
“Based on patients’ reports, this study reveals that physician care may not be as influenced by patient weight as previously thought. Yet, there is a discernable impact of patients’ weight on physician behavior. Overweight men, who may comprise the most at-risk population, indicate that less time is spent with them than that indicated by average weight men. While this may be alarming, overweight women do not report reductions in care. We propose that not only might physicians respond to them differently, but overweight female patients may also be engaging in denial strategies or compensatory behaviors that assure them of quality care.”
“When age, race, income, education, smoking, and health insurance status were adjusted for, the BMI was directly related to delaying clinical breast examinations, gynecologic examinations, and Papanicolaou smears. Obese women were more likely than nonobese women to delay clinical breast examinations, gynecologic examinations, and Papanicolaou smears. The BMI was not significantly related to delays in mammography. It was also related to increased physician visits.”
“The findings show an increase in BMI is associated with an increase in the delay/avoidance of health care. Weight‐related reasons for delaying/avoiding health care included having “gained weight since last health care visit,” not wanting to “get weighed on the provider’s scale,” and knowing they would be told to “lose weight.””
“Obese women reported that they delay cancer-screening tests and perceive that their weight is a barrier to obtaining appropriate health care. The percent of women reporting these statements increased significantly as the women’s BMI increased. The lower screening rate was not a result of lack of available health care since more than 90% of the women had health insurance. Women report that barriers related to their weight contribute to delay of health care. These barriers include disrespectful treatment, embarrassment at being weighed, negative attitudes of providers, unsolicited advice to lose weight, and medical equipment that was too small to be functional. The percentage of women who reported these barriers increased as the women’s BMI increased.”
“Experiences of weight stigmatization, in many forms and across multiple occasions, was common in both samples. A variety of coping strategies were used in response. More frequent exposure to stigma was related to more attempts to cope and higher BMI. Physicians and family members were the most frequent sources of weight bias reported. No gender differences were observed in types or frequency of stigmatization. Frequency of stigmatization was not related to current psychological functioning, although coping responses were associated with emotional well‐being.”
“Obese women commonly delay health care because of weight concerns.”
“Patients undergoing bariatric surgery continue to feel misunderstood and mistreated by medical and non-medical personnel involved in the treatment of their obesity. Like other forms of prejudice, this most likely is due to a lack of understand ing of the disease of morbid obesity, the root causes and the medical consequences if untreated. Despite laws designed to prevent discrimination based on appearance, unfavorable attitudes and practices persist.”
“The lack of availability of different cuff sizes continues being a challenging problem to be faced. The standard cuff available, 12cm large, did not fit 82.7% of the identified AC, resulting in over or underestimated BP registers.”
“For some obese patients, especially those weighing >450 lb, access to emergent CT and MRI is limited, even at academic and bariatric surgery centers. Animal facilities are not a viable alternative for diagnostic imaging of human patients. The limited capacity to obtain diagnostic imaging due to equipment weight limitations may significantly limit the ability to deliver quality emergency care for an important segment of the US population.”
“Prior to the course, the medical students held largely accurate beliefs about the causes of obesity, but they still maintained negative stereotypes of the obese as lazy and lacking in self-control. Analysis of students’ attitudes toward obese patients five weeks and one year after the course indicates that the intervention was effective. At the five-week assessment, students in the intervention group differed from students in the control group on six of eight measures of attitudes toward the obese. One year after the course, the intervention group was significantly more likely to rate genetic factors as important in obesity and less likely to blame the obese for their condition.”
“The current study suggests both that it is possible to conduct a substantive trial of the effects of educational films designed to reduce weight stigma on a larger cohort of trainee healthcare professionals, and that brief educational interventions may be effective in reducing stigmatizing attitudes in this population.”
“Implementing a short educational intervention was effective in improving medical students’ beliefs and stereotypes regarding obese patients. This widely accessible and easily replicable program can serve as a model and springboard for further development of educational interventions to reduce weight bias among medical students.”
VOOR DIKKE PATIËNTEN
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