Impact of weight bias and stigma on quality of care and outcomes for patients with obesity.

The objective of this study was to critically review the empirical evidence from all relevant disciplines regarding obesity stigma in order to (i) determine the implications of obesity stigma for healthcare providers and their patients with obesity and (ii) identify strategies to improve care for patients with obesity. We conducted a search of Medline and PsychInfo for all peer-reviewed papers presenting original empirical data relevant to stigma, bias, discrimination, prejudice and medical care. We then performed a narrative review of the existing empirical evidence regarding the impact of obesity stigma and weight bias for healthcare quality and outcomes. Many healthcare providers hold strong negative attitudes and stereotypes about people with obesity. There is considerable evidence that such attitudes influence person-perceptions, judgment, interpersonal behaviour and decision-making. These attitudes may impact the care they provide. Experiences of or expectations for poor treatment may cause stress and avoidance of care, mistrust of doctors and poor adherence among patients with obesity. Stigma can reduce the quality of care for patients with obesity despite the best intentions of healthcare providers to provide high-quality care. There are several potential intervention strategies that may reduce the impact of obesity stigma on quality of care.

Are prenatal, obstetric, and infant complications associated with postpartum psychosis among women with pre-conception psychiatric hospitalisations?

OBJECTIVE: To examine the associations of maternal and infant complications with postpartum hospitalisation for psychosis in women with a pre-conception history of psychiatric hospitalisation. DESIGN: Population-based study. SETTING: Swedish medical birth register. POPULATION: Primiparous women who gave birth between 1 January 1987 and 31 December 2001, and who had a pre-conception history of psychiatric hospitalisation but who were not hospitalised during pregnancy (n = 1842). METHODS: International Classification of Diseases (ICD) codes were used to identify prenatal, obstetric, postpartum maternal complications, and newborn health conditions. We used multivariable logistic regression to describe the associations between maternal and infant health conditions and the odds for postpartum hospitalisation for psychosis. MAIN OUTCOME MEASURE: Psychiatric hospitalisation within 90 days of delivery. RESULTS: Compared with women who did not have a postpartum psychiatric hospitalisation, hospitalised women were at 2.3 times higher odds (95% CI 1.0-4.9) of having non-psychiatric puerperium complications (e.g. infection, lactation problems or venous complications). No other maternal complications were associated with postpartum psychiatric hospitalisation. Although their infants were at no higher odds for health complications, the offspring of women who had a postpartum psychiatric hospitalisation were at 4.1 times higher odds (95% CI 1.3-12.6) of death within the first 365 days of life than those of women who were not hospitalised. CONCLUSIONS: We found no prenatal indicators of postpartum risk for psychiatric hospitalisation among high-risk women, but they had higher odds of postpartum pregnancy-related medical problems and, rarely, offspring death.

Pregnancy feelings among adolescents awaiting pregnancy test results.

OBJECTIVE: The authors surveyed adolescent girls about their feelings regarding pregnancy. METHODS: A survey was administered to 117 13- to 18-year-olds who obtained pregnancy tests at nine clinics in Minneapolis and St. Paul, Minnesota, in 1998. The survey included four measures of pregnancy feelings. The authors used bivariate and multivariate logistic regression analyses to examine the associations of these measures with engagement with school, future expectations, social and environmental characteristics, and perceived partner desire for pregnancy. RESULTS: The four measures of pregnancy feelings were highly correlated (P = 0.0001). Participants reported a range of positive, negative, and ambivalent feelings on all measures. Perceived partner desire for pregnancy, limited future expectations, and lack of school engagement were significantly associated with positive pregnancy feelings for the four measures. CONCLUSIONS: Successful adolescent pregnancy prevention interventions may include the involvement of partners and key adults as well as strategies to enhance the educational or employment aspirations of girls and adolescents.

Perceived knowledge and training needs in adolescent pregnancy prevention: results from a multidisciplinary survey.

OBJECTIVES: To examine health care professionals' knowledge and interest in training in adolescent pregnancy prevention and whether an association exists between perceived knowledge and interest in training. DESIGN: A cross-sectional mailed survey. PARTICIPANTS: Random, stratified sample design that identified 800 psychologists, 800 social workers, 1,000 nurses, and 400 pediatricians from national professional membership lists. Response rate to the mailed survey was 51%. After removing respondents who did not currently work with adolescents, 1,242 surveys (41%) were available for analyses. MAIN OUTCOME MEASURES: Descriptive analyses were conducted on self-report data concerning perceived knowledge and interest in training about adolescent pregnancy prevention separately for each of the 4 disciplines. Within disciplines, perceived knowledge and interest in training were correlated for each of 3 content areas (ie, sex education and contraceptive counseling, adolescent pregnancy, and counseling after a negative pregnancy test) and for a summary measure of the content areas. RESULTS: Less than half of the nursing, pediatrics, psychology, and social work professionals reported high perceived knowledge in the 3 content areas. Psychologists and social workers reported the lowest perceived knowledge. However, with the exception of psychologists, more than two thirds of the other respondents reported moderate or high interest in training in the 3 content areas. Interest in training was not strongly correlated with perceived knowledge within any discipline. CONCLUSIONS: The need to integrate psychosocial components into adolescent health care is a core assumption in the field, yet these data indicate that psychologists and social workers perceive low levels of knowledge and interest in training. These disciplines may benefit from more targeted professional training about their role in preventing adolescent pregnancy.

Prevalence of home pregnancy testing among adolescents.

OBJECTIVES: This study estimated the prevalence of home pregnancy testing among adolescents. METHODS: A survey was administered in 11 urban clinics to 600 females aged 13 to 19 years. RESULTS: The prevalence of home pregnancy test use was 34% among 474 sexually experienced youths; 77% of the users had received at least 1 negative pregnancy test result, and 48% took no further action for confirmation. Compared with those who had never used such tests, users were older, younger at sexual debut, less likely to consistently use effective birth control, and more likely to have ever been pregnant. CONCLUSIONS: Health care clinics are important sources for pregnancy prevention, but clinics may have limited opportunity to intervene with some youths who use home pregnancy tests.

Evaluation of a community-based program to improve infant immunization rates in rural Minnesota.

OBJECTIVE: The purpose of this study was to evaluate the effects of enrollment in a community-based public health nursing program, Communities Caring for Children (CCC), on infant immunization rates in rural Minnesota. The program involved health education, a registry, and a reminder system. DESIGN: The evaluation was a collaborative effort of university, public health agency, and private managed-care personnel. Two data sources were used to assess the association of program enrollment and immunization compliance; public birth certificates and a telephone survey of 421 CCC enrollees and non-enrollees. RESULTS: Birth certificate and survey data showed that CCC enrollees were significantly younger, less educated, more likely to be white, and of lower parity than non-enrollees. The average age of subjects' infants was eight months. The survey data showed that, overall, CCC enrollees perceived less danger in infant immunizations than did non-enrollees and were more likely than non-enrollees to have access to infant immunization reminder cards. CCC enrollees reported significantly higher immunization compliance for their infants than did non-enrollees. CONCLUSIONS: The area served by this program is relatively low-income and rural. Infant immunization status was among the lowest in Minnesota prior to the implementation of CCC. The evaluation suggested that enrollment in CCC was one of the most powerful predictors of infant immunization compliance.

Adolescent satisfaction with postpartum contraception and body weight concerns.

PURPOSE: To explore factors that could be related to adolescents' satisfaction with postpartum contraceptives. METHODS: Three focus groups were conducted with a total of 22 adolescent mothers. The groups covered four content areas: feelings about birth control since becoming a mother, decision making about contraceptive use, factors that would influence contraceptive discontinuation, and the perceived side effects of the current contraceptive. Audiotapes from the groups were analyzed to identify major themes. RESULTS: Nineteen subjects received Depo-Provera when they were discharged after delivery and the majority reported that menstrual irregularities and weight gain were side effects. Two body weight-related themes were dominant: dissatisfaction with heavier than desired body weights and resignation about not returning to prepregnancy weights. CONCLUSIONS: Depo-Provera may be an effective contraceptive for adolescent mothers who are generally at high risk for rapid repeat pregnancy. This qualitative study suggests that contraceptive continuation may be enhanced with specific counselling to manage body weight concerns.

PIP: Factors having a potential effect on adolescents' use of and satisfaction with postpartum contraceptive methods were assessed in three focus groups involving 22 adolescent mothers of an infant under 12 months of age recruited from a Minnesota (US) clinic specializing in the prenatal and postpartum care of adolescent women. The average age of study participants was 17 years (range, 13-19 years). All adolescents chose to use contraception after delivery. 16 (73%) were using Depo-Provera, 3 were using oral contraceptives, and 3 were using condoms/foam. Most Depo-Provera users made their decision to accept this method with their prenatal care provider during pregnancy. Many had taken the pill at some point, but reported it was hard for them to take it every day. Despite concerns about side effects (especially increased hunger/weight gain and irregular menstrual bleeding), adolescent Depo-Provera acceptors preferred this method because it did not require daily compliance. 16 women (73%) considered themselves overweight, and they attributed this to both their pregnancy weight gain and their contraceptive method. Skepticism regarding their ability to lose weight through healthy eating and exercise was widespread. However, the desire to prevent another pregnancy through use of an effective method such as Depo-Provera was stronger than the desire to return to one's pre-pregnancy body weight. Overall, these adolescent mothers seemed resigned about their inability as a result of the demands of motherhood to resolve their malaise, fatigue, and sense of not being physically fit. These findings suggest a need for effective weight management and health-promoting programs for adolescent mothers that take into account their multiple role demands and generally limited financial resources.

Differences in preconceptional and prenatal behaviors in women with intended and unintended pregnancies.

OBJECTIVES: This study examined whether pregnancy intention was associated with cigarette smoking, alcohol drinking, use of vitamins, and consumption of caffeinated drinks prior to pregnancy and in early pregnancy. METHODS: Data from a telephone survey of 7174 pregnant women were analyzed. RESULTS: In comparison with women whose pregnancies were intended, women with unintended pregnancies were more likely to report cigarette smoking and less likely to report daily vitamin use. Women with unintended pregnancies were also less likely to decrease consumption of caffeinated beverages or increase daily vitamin use. CONCLUSIONS: Pregnancy intention was associated with health behaviors, prior to pregnancy and in early pregnancy, that may influence pregnancy course and birth outcomes.

The association of job strain and health behaviours in men and women.

BACKGROUND: This study examined whether self-reported job strain, defined by the Karasek model was associated with some early, potentially modifiable cardiovascular (CVD)-related health characteristics. METHODS: Data were gathered in a 1989 cross-sectional survey of 3843 randomly selected men and women employees of 32 worksites in Minnesota. Sex-stratified crude and multivariate analyses examined the independent association of job psychological demands, latitude, and the combination of these two job domains (i.e. strain), to body mass index (BMI), smoking, exercise, and dietary fat intake. RESULTS: Job demands was positively associated with smoking, smoking intensity, and high fat intake in men and with BMI and smoking intensity in women. Job latitude was positively associated with exercise in men and women. High-strain men smokers smoked more than other workers and high-strain women had higher BMI than other women. CONCLUSIONS: Overall, self-reported job demands, latitude, and job strain were associated with some CVD-related health characteristics, but the effects were not similar in magnitude or direction for all characteristics and they varied by sex.

The effects of cigarette smoking and gestational weight change on birth outcomes in obese and normal-weight women.

OBJECTIVES: The associations of infant birth outcomes with maternal pregravid obesity, gestational weight gain, and prenatal cigarette smoking were examined. METHODS: A retrospective analysis of 1343 obese and normal-weight gravidas evaluated the associations of cigarette smoking, gestational weight change, and pregravid body mass index with birthweight, low birthweight, and small- and large-for-gestational-age births. RESULTS: Smoking was associated with the delivery of lower-birthweight infants for both obese and normal-weight women, and gestational weight gain did not eliminate the birthweight-lowering effects of smoking. Women at highest risk of delivering lower-birthweight infants were obese smokers whose gestational gains were less than 7 kg and normal-weight smokers whose gestational gains were less than 11.5 kg. CONCLUSIONS: To balance the risks of small and large-size infants, gains of 7 to 11.5 kg for obese women and 11.5 to 16 kg for normal-weight women appear appropriate.

Association of maternal psychological functioning to pathology in child sexual abuse victims.

The purpose of this study was to assess the psychological impact of disclosure of sexual abuse on child victims and their mothers and evaluate whether there was an association between maternal distress and report of child behavioral and psychological problems. Data on child psychological and behavioral problems and maternal psychological functioning were collected at the time of disclosure of sexual abuse and 9 months later for 49 subjects. The study showed the heterogeneity and severity of problems among victims and their mothers at baseline. These problems persisted almost a year later. Maternal distress was strongly correlated with the mothers' assessments of child functioning and was less strongly associated with the children's own assessments of their status. Because the mothers in this study reported high levels of persistent distress for themselves and their children, comprehensive intervention with the family may be an efficient route to child recovery after disclosure of sexual abuse.

The effects of a telephone-based intervention on weight loss.

PURPOSE: To evaluate minimal-contact and telephone-assisted weight-loss programs for overweight persons. DESIGN: Participants were randomized to a minimal-contact group or one of two telephone-assisted weight-loss groups. All participants attended two group-based behavioral weight-loss classes and received written educational materials and diaries. For the subsequent 24 weeks, the minimal-contact group received no contact and the telephone-assisted group members received weekly calls to monitor their weight, food intake, and exercise. SETTING: Baseline educational sessions and data collection were conducted at a university site. SUBJECTS: Sixty-four healthy subjects (4 men) who were from 120% to 150% of ideal weight and were 25 to 55 years of age participated in the study. MEASURES: The major outcome of interest was change in measured weight over a 24-week period. Data on calories expended in exercise, dietary intake, and demographics were also gathered at baseline and 24 weeks. RESULTS: Weight loss did not differ significantly by treatment. Unexpectedly, the minimal-contact group lost almost twice as much weight as the telephone-assisted groups (12.7 vs 7.9 lb). CONCLUSIONS: There appears to be an audience for low-contact and telephone-assisted weight-loss programs, and such programs can be delivered easily. However, because the data show only modest weight-loss success, work should continue to identify the optimal content and design of such interventions.

Effects of a personal trainer and financial incentives on exercise adherence in overweight women in a behavioral weight loss program.

Exercise is important for long-term weight loss, but few studies have examined ways to improve exercise adherence in overweight subjects participating in a behavioral weight loss program. This paper presents two studies, one conducted at the University of Pittsburgh and one at the University of Minnesota, that sought to improve exercise adherence by exerting more direct control over the environmental antecedents and consequences controlling exercise. Study 1 investigated the use of a personal trainer who called participants regularly and met them at their home or office at scheduled times for a walk. Study 2 investigated the effect of a lottery incentive for exercise adherence. In both studies, the effect of these manipulations was examined in the context of a 24-week standard behavioral weight control program with three supervised exercise sessions per week. Neither intervention achieved statistically significant improvements in exercise adherence compared to control conditions, perhaps due in part to the limited statistical power of the studies. Future studies should focus on better understanding the barriers to exercise and designing behavioral interventions that address these barriers.

Pregnancy complications and birth outcomes in obese and normal-weight women: effects of gestational weight change.

OBJECTIVE: To compare the pregnancy course and outcomes in obese and normal-weight women and their associations with gestational weight change. METHODS: Multivariate logistic regression described the relation of weight change to pregnancy course and outcomes in a retrospective study of 683 obese and 660 normal-weight women who delivered singleton living neonates. RESULTS: Compared with normal-weight women, obese women gained an average of 5 kg (11 lb) less during pregnancy and were more likely to lose or gain no weight (11% versus less than 1%). Obese women were significantly more likely to have pregnancy complications, but the incidence of complications was not associated with weight change. Compared with obese women who gained 7-11.5 kg (15-25 lb), obese women who lost or gained no weight were at higher risk for delivery of infants under 3000 g or small for gestational age infants, and those who gained more than 16 kg (35 lb) were at twice the risk for delivery of infants who were 4000 g or heavier. CONCLUSION: Gestational weight change was not associated with pregnancy complications in obese or normal-weight women. To optimize fetal growth, weight gains of 7-11.5 kg (15-25 lb) for obese women and 11.5-16 kg (25-35 lb) for normal-weight women appear to be appropriate.

Effect of frequent phone contacts and Optional Food Provision on maintenance of weight loss.

This article reports the results of two studies evaluating strategies to improve maintenance of weight loss. Study 1 evaluated the effect of frequent contact with patients through phone calls designed to promote adherence to self-monitoring; Study 2 evaluated a crisis intervention model, where subjects could obtain food boxes during high-risk periods to simplify dietary adherence. All subjects had originally participated in an initial six-month behavioral weight control program conducted at the University of Minnesota or at the University of Pittsburgh and had lost >4.0 kg. Subjects from the University of Minnesota (N=53) were randomly assigned to either a year-long maintenance program involving weekly phone calls from a staff member or to a no-contact control (Study 1). Weekly phone calls, which inquired about self-monitoring and current weight, were completed with high frequency (76% completion rate); call completion and self-reported adherence to daily monitoring were negatively associated with weight regain (r=-0.52 to -0.59, p<.01). However, weight regain did not differ significantly in the Phone Maintenance versus Control Condition (+3.9 kg versus +5.6 kg, p=.28). Study 2, conducted at the University of Pittsburgh, involved 47 subjects who were randomly assigned to a Control or Optional Food Provision Condition. Both groups attended monthly maintenance meetings; the Food Provision Group had the option of purchasing boxes of food containing five breakfasts and five dinners. Twelve of the 26 subjects in the Food Provision Group purchased these food boxes for at least one month of maintenance. However, weight regain in those people who purchased the box, or in the Food Provision Condition as a whole, did not differ from the Control Condition (+4.2 kg for intervention versus +4.3 kg for control). Further research is needed to develop more effective maintenance interventions.

Adolescent parity and infant mortality, Minnesota, 1980 through 1988.

The association of parity and infant mortality was studied using linked birth-death files for 46,985 infants born to 11- to 19-year-old Minnesota residents between 1980 and 1988. Compared with infants of primiparas, infants of multiparas were at twice the risk for infant and postneonatal death but at no increased risk for neonatal death. They were also at two to three times the risk for deaths due to accidents, infections, and sudden infant death syndrome. The higher sociodemographic disadvantage and poorer prenatal care of multiparas did not explain the excess infant mortality risk that was concentrated in causes of death that are potentially preventable through primary care and parent education.

A prospective study of effects of weight cycling on cardiovascular risk factors.

BACKGROUND: The possible adverse health effects of weight cycling (weight loss followed by weight regain) have been the subject of recent concern. To determine whether such weight cycling negatively influences cardiovascular risk factors, 153 overweight individuals were followed up prospectively through a 30-month weight loss and maintenance program. METHODS: Subjects were divided into seven groups according to their weight-change patterns during this 30-month study (steady weight loss of different magnitudes, weight gain, no change in weight, and different weight-cycling patterns). These weight-change groups were compared with regard to lipid levels, blood pressure measurements, waist-to-hip ratio, and percent body fat at 0, 6, 12, 18, and 30 months. RESULTS: No adverse effects of weight cycling on any of the cardiovascular risk factors were observed. Subjects who initially lost 9.0 kg or more and then regained it did not differ from those who had no change in weight with regard to any cardiovascular risk factor at month 30. Subjects who gained weight during the 30-month interval increased their risk factors, those who lost weight decreased their risk factors in proportion to the magnitude of weight loss, and, in general, cardiovascular risk factors at month 30 were related to the net weight loss achieved and not the route taken to achieve the weight loss. CONCLUSIONS: This study showed no negative effects of weight cycling on cardiovascular risk factors and confirmed previous findings of positive effects of weight loss on risk factors. Therefore, overweight individuals should be encouraged to lose weight and then maintain their weight loss.

A randomized trial of counseling for fat restriction versus calorie restriction in the treatment of obesity.

OBJECTIVE: to evaluate the effectiveness of dietary counseling focusing on fat reduction (20 g/day) compared to calorie reduction (1000 to 1200 kcal/day) in promoting long-term weight loss in moderately obese women. DESIGN: One hundred and twenty-two women were randomized to one of the two treatment groups and received intensive dietary counseling in groups of 20 over a period of 18 months. RESULTS: Among 74 women completing the study, weight losses at 6 months averaged 10.2 lb (n = 39) in the fat counseling group and 8.1 lb (n = 35) in the calorie counseling group. Average weight returned to baseline levels in both groups over the succeeding 12 months despite continued intervention. CONCLUSION: Although these data provide little support for the immediate clinical utility of low-fat dietary counseling in obesity treatment, the observation that women in the low-fat group were more compliant with treatment directions, rated the diet as being more palatable, and experienced greater reduction in binge eating scores suggests that this approach warrants further study. In addition, time dependent covariance analysis showed that change in fat intake predicted weight change better than change in total energy intake, thus reinforcing the idea that dietary fat may be an important factor in the etiology and treatment of obesity.

Evaluation of weight reduction in a community intervention for cardiovascular disease risk: changes in body mass index in the Minnesota Heart Health Program.

This paper describes the effectiveness of the Minnesota Heart Health Program (MHHP) in modifying mean body mass index (BMI) in whole communities. The MHHP is a 13-year research and demonstration project designed to reduce cardiovascular risk. One member of each of three pairs of matched communities received 7 years of community intervention activities that included risk factor screening, mass media education, adult education classes, worksite interventions, home correspondence programs, school-based programs, restaurant programs, and point-of-purchase education in supermarkets. Weight gain prevention was emphasized for all adults and weight loss was encouraged among those who were obese or who had elevated risk factors known to be responsive to weight loss (e.g., high blood pressure). A strong upward secular trend in weight was noted in all MHHP communities over time. Intervention effects were evaluated conservatively with community as the unit of analysis. This analysis showed no overall effect of the MHHP intervention program on mean BMI. However, a positive intervention effect was noted early in the intervention among those with elevated cholesterol or a history of obesity-related disease. Possible reasons for this relatively weak community effect are discussed, including secular forces overwhelming intervention effects, an intervention effort not sufficiently focused on obesity, ceiling effects for weight concern in a population that was highly aware of the issue at baseline, and inherent limitations in educational approaches for this recalcitrant public health problem.

Brief supportive telephone outreach as a recruitment and intervention strategy for smoking cessation.

BACKGROUND: Formal efforts to recruit smokers into cessation programs have failed to reach large segments of the smoking population. Telephone intervention may represent a viable strategy to promote smoking cessation. An even more promising approach may be a combination of brief telephone support and outreach to identified smokers. METHODS: Telephone support for smoking cessation was provided to four identified smoker populations in Bloomington, Minn, one of three Minnesota Heart Health Program education communities. Smokers were randomly assigned to an intervention consisting of two 15-minute telephone calls approximately 1 to 3 weeks apart or to a nonintervention control. RESULTS: At the 6-month follow-up, a significant overall effect was found in favor of the intervention condition for both self-reported and cotinine-validated quitting. Differences between intervention and control conditions were no longer significant at 18 months. CONCLUSIONS: Smokers' receptivity to telephone intervention was at least moderately encouraging. The cost of intervention could be relatively low if trained volunteers initiated telephone calls. However, more intensive telephone intervention and support may be needed to produce lasting changes in smoking prevalence.