Who's Obese? Patients, Doctors Differ

Obesity Health Warnings Ignore Racial, Cultural Diversity

From the WebMD Archives

April 27, 2006 -- When our doctors tell us to lose weight, what we hear may not be a health message.

It's particularly true for black patients, a study from Yale University School of Nursing shows.

The study shows that when doctors talk about a patient's weight, they are talking about body size. But what patients hear is that the doctor has different ideas than they do about things like attractiveness, sexual desirability, body image, strength or goodness, self-esteem, and social acceptability.

Yale doctoral student Maryanne Davidson, MSN, RN, CPNP, and Kathleen A. Knafl, PhD, now at Oregon Health & Science University, report the findings in the May issue of the Journal of Advanced Nursing.

"There is such a disconnect between what we health care providers mean when we talk about obesity and overweight, and what those concepts mean to different people," Davidson tells WebMD. "We say, 'Your health is affected by the size of your body.' But patients don't necessarily connect those terms to the belief that their health is affected."

Blacks, Whites See Size Differently

Davidson and Knafl analyzed 20 papers from 18 different studies on patients' concepts of obesity and analyzed each study.

"I looked at what these researchers found when patients talked to them about obesity and overweight," Davidson says. "I looked at the differences and similarities between the groups and what that might mean for us as health care providers."

The studies consistently showed that larger body sizes are more socially acceptable -- and more desirable -- to black women and men than to white women and men.

"Black men find black women at a larger body size to be attractive, and black women feel attractive at a larger body size," Davidson says. "White women talked about feeling unattractive at a larger body size, and they did not find it socially acceptable."

The finding does not surprise Sheila P. Davis, PhD, professor of nursing at the University of Mississippi Medical Center in Jackson. Davis studies overweight children and their families.

"It seems as if for black women -- and I am a black woman -- obesity doesn't carry the same negative associations as it does for white women, Davis tells WebMD.

University of Cincinnati pediatrician Frank Biro, MD, associate director of adolescent medicine at Cincinnati Children's Hospital, has studied how different cultures see body size differently.

"You see in the scientific literature that African-American women are comfortable with a thicker body shape," Biro says. "That is the specific word they use -- thick. And it's a very good word. If you think about thin, someone could be thicker."

Where races differ less is in relating obesity to health. For both blacks and whites, the message isn't clear.

"When it comes to health, many African-Americans do not associate being overweight or obese with larger body size," Davidson says. "Even with white women, it was minimized. Some did not believe it. It is concerning that is so common, because health care providers only use the terms 'BMI,' 'overweight,' and 'obesity' to talk about body size."

When Body Size Does Affect Health

Feeling good about not being pencil-thin is a good thing. It shows that a person has good self-esteem. But there's a point at which being too thick or too thin just isn't healthy. And these days, being too thick is much more prevalent.

Regardless of how we see ourselves, there's a point at which our body mass makes us ill. Obesity is directly related to problems that include -- but aren't limited to -- diabetes, heart disease, asthma, and some cancers.

"Being comfortable with your body, that is good for self-esteem," Biro says. "But suppose your body mass puts you in the category of being very obese. That is not a good thing. At very high body mass, you increase the risks to your health. So being more comfortable with a moderately overweight body size is probably good. But being comfortable with an obese body size is not a good thing for you, because you put yourself at much greater risk of adverse health outcomes."

Unfortunately, Davidson found, people aren't connecting what doctors call obesity with too-big body size.

"The hard part is, regardless of how you see yourself, you are going to hit a certain weight that leads to illnesses associated with too much weight," she says. "We have to get away from weight being about beauty and attractiveness and desirability. We have to stop talking about those things when it comes to health. What predominately white health care providers are saying to African-Americans doesn't have any meaning."

In her work with black families, Davis finds that when she talks about obesity, nobody listens. But when she talks about health, people not only listen -- they change their behavior.

Davis and colleagues interviewed obese children and their parents -- mostly mothers, nearly all of whom turned out to be obese. They asked the children, and then the parents, about their experiences and about how they saw things.

"When we began to share with parents the fact that their children were being teased about being obese, the parents made excuses," Davis says. "They said things like, 'It's in the genes,' and so on. They didn't seem to be concerned. But we noticed a big change in mood when talked about the health aspects of their children's body size. With no further provocation from us, the parents began to form groups to get together and exercise, and make healthier meals."

The lesson, Davidson says, is that health care providers have to sing a different tune.

"We know we are missing something. What is it?" she asks. "What I see clinically is people saying, 'What you are talking about doesn't apply to us.' But just because we can't get past the fact I am labeling you with a term you feel doesn't fit you doesn't mean we don't have a health problem here."

Like Davis, Davidson finds the discussion about obesity has to focus on health, not weight itself.

"If you went to a doctor and he said, 'Your nose is a mess, I'm sending you to surgery,' would you do anything about that? No," she says. "But if the doctor said, 'You can't breathe right, we need to straighten your nose out. It will change your appearance, but you will sleep better, and have fewer health problems,' you'd be much more likely to listen."

Show Sources

SOURCES: Davidson, M. Journal of Advanced Nursing, May 2006; vol 54: pp 342-350. Maryanne Davidson, MSN, RN, CPNP, doctoral student, Yale University School of Nursing, New Haven, Conn. Frank Biro, MD, associate director of adolescent medicine, Cincinnati Children's Hospital, and professor of pediatrics, University of Cincinnati, Ohio. Sheila P. Davis, PhD, professor of nursing, University of Mississippi Medical Center, Jackson.

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