Outcomes Research in Review

Are There Racial/Ethnic Differences in Weight-Related Care Encounters Reported by Patients?

Lewis KH, Gudzune KA, Fischer H, et al. Racial and ethnic minority patients report different weight-related care experiences than non-Hispanic Whites. Prev Med Rep 2016;4:296–302.


 

References

Study Overview

Objective. To compare patients’ health care experiences related to their weight across racial and ethnic groups.

Design. Cross-sectional survey-based study.

Setting and participants. Between March and July 2015, 5400 individuals were randomly sampled from the Patient Outcomes to Advance Learning (PORTAL) obesity cohort, which includes over 5 million adults. The PORTAL network is a clinical data research network funded by the Patient Centered Outcomes Research Institute to promote collaboration across several large health systems with electronic medical records (EMRs), including all the Kaiser Permanente regions, Group Health Cooperative, Health Partners, and Denver Health. The selected 5400 cohort members were equally distributed across 3 geographically diverse Kaiser Permanente regions (Southwest, Northern and Southern California, Hawaii, Colorado, and Northwest) and Denver sites. Selected individuals were non-pregnant English or Spanish speakers with a body mass index (BMI) ≥ 25 kg/m 2 (per their EMR) who were members of a participating health plan and had at least 1 outpatient visit in the last 12 months. Patients with BMI ≥ 40 kg/m 2 were oversampled. Individuals were mailed a written 10-minute survey (offered in English or Spanish based on a patient’s written language preference noted in their EMR), consisting of 36 multiple-choice and fill-in-the-blank items. Telephone contact for verbal administration was attempted if a mailed response was not received within 4 weeks.

Main measures and analysis. The primary independent variable was a respondent’s racial/ethnic group, categorized as (1) non-Hispanic white (White), 2) non-Hispanic black (Black), 3) Hispanic, 4) Asian, or 5) Native Hawaiian/Other Pacific Islanders/American Indian/Native Alaskan (NA/PI).

Dependent variables focused on patients’ perceptions of the health care experience (based on services received at their usual place of care from their primary care providers) related to being overweight or obese using items based on the Rudd Center’s Patient Survey of Weight-Sensitive Healthcare Practices. Respondents described (1) whether and how often they avoid coming to their provider because they do not want to be weighed or have a discussion about their weight; (2) how often does their provider ask their permission before discussion their weight; (3) how often has their provider been supportive of their weight concerns and efforts to be healthy; (4) whether they think that their provider understands the physical and emotional challenges faced by individuals who are overweight or obese; (5) how often has their provider brought up their weight during a clinic visit; (6) whether their provider has ever given or discussed resources on healthy eating and weight loss; and (7) what types of weight loss resources were discussed with their provider and which types did they want more information about (ie, dietary changes, physical activity, classes, medications, meal replacements, and bariatric surgery). Covariate variables derived from EMR data included sex, age category, diabetes, hypertension, Charlson Index score (overall measures of morbidity), Medicaid enrollment, language preferences, site, and BMI. Survey-derived covariate variables included emotional well-being, perceived weight status, and educational attainment.

Descriptive statistics were generated and compared across racial/ethnic groups using Kruskal-Wallis and chi-square testing, as appropriate. To evaluate the association between a patient’s race/ethnicity and their perceived weight management experience, multinomial logistic regression adjusted for covariates was used to estimate odds ratios (OR).

Main results . From the original sample (n = 5400), 1569 individuals (29%) did not respond, 925 (17%) refused, and 114 (2%) were ineligible, leaving an eligible sample pool of 5286 individuals. The overall response rate was 53% (2197 written; 614 phone, n = 2811). Those with missing data were excluded (6 with missing race/ethnicity; 80 missing other covariates), leaving a final group of 2725 respondents for analysis. Mean age was 52.7 years (SD 15), almost 62% of participants were female, 51.7% identified as White, 21.1% identified as Black, 14.6% identified as Hispanic, 5.8% identified as Asian, and 6.7% identified as NA/PI. About a quarter (24.4%) had diabetes, less than half (43.5%) had hypertension, and most (86.2%) perceived themselves to be overweight. There were significant differences in measured baseline covariates by racial/ethnic groups including mean BMI, diabetes, and being a Medicaid beneficiary.

In response to the 7 key areas assessed regarding patients’ perceptions of the health care experience related to being overweight or obese:

  • Black respondents were less likely than Whites to report that they frequently avoided care from their provider because they did not want to be weighed or discuss their weight (OR 0.49 [95% confidence interval, 0.26–0.90]), with a trend toward all groups being less likely to report frequent avoidance compared to Whites.
  • While just over half of respondents (59.3%) indicated that their providers never asked for their permission before discussing their weight, Asians and NA/PI were more likely to report that their providers either frequently (Asians: OR 2.7 [1.3–5.6]; NA/PI: OR 2.3 [1.1–5.0]) or sometimes (Asians: OR 2.3 [1.2–4.3]; NA/PI: OR 2.1 [1.1–4.1]) asked their permission before discussing their weight compared to Whites.
  • Over half (61.9%) indicated that their providers were sometimes or frequently supportive of their weight concerns, with no significant differences among racial/ethnic groups.
  • Just over half (52.0%) indicated they felt their providers understood the physical and emotional challenges faced by people who are overweight/obese, with Blacks more likely to feel this way (OR 1.8 [1.2–2.8]) compared to Whites.
  • Black patients were more likely than Whites (OR 2.0 [1.4–2.8]) to report that their providers discussed their weight with them at a clinic visit.
  • While over half (59.7%) indicated that their providers had given or discussed resources with them on healthy eating and weight loss, Black and Asian respondents were more likely than Whites to recall these discussions (Black: OR 1.6 [1.2–2.1]; Asians: OR 1.8 [1.1–2.9]).
  • Most weight loss resources or recommendations received were related to lifestyle changes, with very few resources given related to weight loss medications, meal replacement products, or bariatric surgery—few differences across racial/ethnic groups were identified. However, respondents from racial/ethnic minority groups were more likely than Whites to say that they wanted more information about lifestyle changes, classes, and meal replacements. Other than Blacks, all other racial/ethnic groups were also more likely than Whites to indicate that they wanted more information about bariatric surgery.

Conclusions. Most patients across racial/ethnic groups are having positive experiences with weight-related care. However, race/ethnicity correlates with patients’ perception of weight-related care and discussions in clinic encounters.

Commentary

The obesity epidemic in the United States is well-established [1], and recent data from 2014 show that over 37% of adults in the US are obese (defined as having a body mass index greater than 30 kg/m 2) [2]. However, while obesity prevalence rates have increased over the past several decades across all genders, ethnicities, income levels, and education levels, important racial/ethnic disparities exist [2,3]. Primary care physicians (PCPs) are ideally situated to promote weight loss via effective obesity counseling since multiple clinic visits over time have the potential to enable rapport building and behavioral change management [4]. In fact, the US Preventive Services Task Force (USPTF) recommends that all patients be screened for obesity and offered intensive lifestyle counseling, as modest weight loss can have significant health benefits [5]. However, some studies have found racial/ethnic differences and disparities in weight-related diagnoses, counseling, and treatment by providers, but also patient perceptions of care and preferred interventions [6–10]. Other studies have described racial/ethnic differences in weight-related concerns and behaviors, body satisfaction, and body image [11–13]. Thus, research is needed to examine these differences.

This cross-sectional study contributes to the limited literature examining the potential for heterogeneity of care according to patient characteristics like race and ethnicity. Key strengths of the design include a large and both geographically and racially/ethnically diverse sample of patients (increased generalizability), the use of mailed brief surveys (reduces non-response rate and reporting bias) and telephone follow-up for verbal administration (reduces non-response rate, though it increases interviewer bias), oversampling of respondents with BMI ≥ 40 kg/m 2, and the controlling of key covariates including sex, age, Medicaid enrollment, site, and BMI.

However, there are several important limitations, many of which are acknowledged by the authors. While respondents were overall representative of the targeted sample population, the final respondent population was comprised of mostly older females who received managed care, which may have contributed to selection bias and impacted generalizability of findings. Further, Whites were overrepresented, Hispanics were underrepresented, and the small combined sample of NA/PI may have masked important distinctions between these subpopulations. Importantly, this study only provided the survey in English and Spanish and did not include other language translations (eg, Chinese, Japanese, Tagalog), which likely contributed to underrepresented perspectives of immigrants and ESL patients who may struggle with receiving/discussing weight management counseling and resources. The use of a surveys collected subjective and self-reported data on patient encounters as opposed to objective observations. Lastly, the study did not adjust for individual provider factors or assess the potential impact of provider-level differences on care, such as provider-patient concordance on race, ethnicity, language, and/or weight. The incorporation of qualitative interviewers or focus groups with a subsample of each racial/ethnic may have also provided relevant context to understand differences in weight-related care experiences.

Applications for Clinical Practice

As the authors suggest, this study highlights several opportunities to continue improving weight-related care and weight management counseling. PCPs should engage all overweight/obese patients in weight management discussions, and in particular, high-risk minority patients who may desire these conversations and more weight loss advice and resources. However, these discussions require sensitivity and can benefit from the simple practice of asking permission of the patient to talk about their weight in order to reduce care avoidance and improve perceptions of care. Providers should also be mindful of patient priorities and assess patient preferences for all the different weight loss strategies, including lifestyle changes, meal replacements, medications, and surgery.

—Katrina F. Mateo, MPH

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